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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200760
Report Date: 11/30/2021
Date Signed: 11/30/2021 01:56:12 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/16/2020 and conducted by Evaluator Laura Hall
COMPLAINT CONTROL NUMBER: 15-AS-20201116095524
FACILITY NAME:ROSE ARBOR SENIOR RESIDENTIAL CARE, LLCFACILITY NUMBER:
019200760
ADMINISTRATOR:XU, LILIFACILITY TYPE:
740
ADDRESS:5901 ROSE ARBOR AVETELEPHONE:
(510) 366-9618
CITY:SAN PABLOSTATE: CAZIP CODE:
94806
CAPACITY:12CENSUS: 0DATE:
11/30/2021
ANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Angela Wang, Licensee, and Lili Xu, AdministratorTIME COMPLETED:
01:30 PM
ALLEGATION(S):
1
2
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8
9
Resident eloped from facility.
INVESTIGATION FINDINGS:
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3
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5
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8
9
10
11
12
13
On 11/30/2021 at 01:00, Licensing Program Analyst (LPA) L. Hall arrived announced to deliver complaint findings for the allegation above. LPA met with Angela Wang, Licensee and Lili Xu, Administrator and explained the reason for the visit.

The allegation of Resident eloped from the facility was accepted by the Department's Investigations Branch (IB) as a full investigation. The Department conducted interviews with both former and current staff, witnesses, resident, and reviewed records. Based on evidence obtained it is substantiated that Resident 1 (R1) eloped from the facility on at least two occasions due to a lack of supervision. During interviews with staff it was confirmed that R1 eloped on two occasions on unknown dates.

Continued on LIC9099C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 15-AS-20201116095524
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ROSE ARBOR SENIOR RESIDENTIAL CARE, LLC
FACILITY NUMBER: 019200760
VISIT DATE: 11/30/2021
NARRATIVE
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Continued from LIC9099.

Based on interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

Exit interview conducted. Appeal rights and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20201116095524
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ROSE ARBOR SENIOR RESIDENTIAL CARE, LLC
FACILITY NUMBER: 019200760
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/30/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/07/2021
Section Cited
CCR
87705(c)(4)
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87705 (c) Licensees who accept... residents with dementia shall... ensuring the following: 4) ...an adequate number of direct care staff to support each resident’s... safety and health care needs... This requirement was not met as evidence by:
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Administrator agreed to review regulation 87705 and submit a plan to keep resident safe and from eloping. Plan will be submitted to CCLD by POC date.
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Based on interviews the Licensee did not comply with the section cited above to keep resident safe, which poses a potential health and safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/16/2020 and conducted by Evaluator Laura Hall
COMPLAINT CONTROL NUMBER: 15-AS-20201116095524

FACILITY NAME:ROSE ARBOR SENIOR RESIDENTIAL CARE, LLCFACILITY NUMBER:
019200760
ADMINISTRATOR:XU, LILIFACILITY TYPE:
740
ADDRESS:5901 ROSE ARBOR AVETELEPHONE:
(510) 366-9618
CITY:SAN PABLOSTATE: CAZIP CODE:
94806
CAPACITY:12CENSUS: 0DATE:
11/30/2021
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Angela Wang, Licensee and Lili Xu, AdministratorTIME COMPLETED:
01:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident sustained unexplained bruises.

Resident was not accorded dignity in relationships with staff.
INVESTIGATION FINDINGS:
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5
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On 11/30/2021 at 01:00, Licensing Program Analyst (LPA) L. Hall arrived unannounced to deliver complaint findings for the allegation above. LPA met with Angela Wang, Licensee and Lili Xu, Administrator and explained the reason for the visit.

The allegation of resident sustained unexplained bruises was accepted by the Department's Investigations Branch (IB) as a full investigation. The Department conducted interviews with both former and current staff, witnesses, resident, and reviewed records. Based on record reviews and interviews by the Department, there was insufficient evidence to substantiate that bruises found on Resident 1 (R1) were sustained at the facility or caused by facility staff. Staff took photos of R1 prior to leaving with W8 for a medical appointment on 11/11/2020.

Continued on LIC9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20201116095524
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ROSE ARBOR SENIOR RESIDENTIAL CARE, LLC
FACILITY NUMBER: 019200760
VISIT DATE: 11/30/2021
NARRATIVE
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Continued from LIC9099.

Witness 8 (W8) did not report any incidents when R1 was with him. Staff observed a bruise forming by R1’s eye the morning of 11/12/2020 but did not observe any bruises on R1’s arms or legs. There were no disclosures of any abuse at the facility from the facility staff or a resident.

On the allegation Resident was not accorded dignity in relationships with staff. During interviews five (5) staff denied any inappropriate behavior or mistreatment of any resident. During interview with Resident 9 (R9) it was stated that the staff never got angry with R1. R9 had no problems or concerns with how the residents were treated at the facility. R9 felt safe and comfortable and did not observe any inappropriate behavior towards the residents.

Based upon the information obtained during investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted and a copy of report was given.

SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5