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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200599
Report Date: 12/16/2022
Date Signed: 12/16/2022 02:45:23 PM

Document Has Been Signed on 12/16/2022 02:45 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:ROSE'S GARDEN ADULT RESIDENTIAL 2FACILITY NUMBER:
079200599
ADMINISTRATOR:JOSE L NUNES, JRFACILITY TYPE:
735
ADDRESS:1617 MONTEREY DRIVETELEPHONE:
(925) 864-7564
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 6CENSUS: 6DATE:
12/16/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Michael Quispe Segama, StaffTIME COMPLETED:
02:50 PM
NARRATIVE
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On 12/16/2022 at 01:00PM Licensing Program Analysts (LPA) L. Hall and C. Fowler conducted an unannounced Case Management visit regarding two (2) separate incident reports received for Client 1 (C1). LPAs met with Michael Quispe Segama, Staff and explained the purpose of the visit. Administrator, Jose Nunes, arrived at 01:15PM.

Upon arrival LPAs was greeted by Staff 3 (S3) whom was not associated to the facility.

Incident report sent on 12/11/2022 was for an AWOL. Staff 1 (S1) stated that the entire incident was resolved within 25 minutes. C1 had been trying to AWOL since the morning of the incident. S1 stated he was on an outing with other the clients and Staff 2 (S2) was at the facility with C1 and Client 2 (C2). C1 was not on the outing due to trying to AWOL. S1 stated C1 has been challenging since C1's parents moved away. S1 stated that staff has been working with C1's behaviorist specialist to help C1 with AWOL.

Incident report sent 12/12/2022 was for a physical altercation between C1 and Client 3 (C3). S1 stated that C1 and C3 have been roommates for over a year and there was one (1) prior incident that occurred on 2/26/2022. Facility staff is working with C1's behaviorist specialist to help with C1's aggression.

Continued on LIC809C.



SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 12/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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'S GARDEN ADULT RESIDENTIAL 2
FACILITY NUMBER: 079200599
VISIT DATE: 12/16/2022
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Continued from LIC809.

LPAs collected the following documents during visit: facility roster, staff roster, and incident reported dated 2/26/2022.

LPAs observed the following deficiency.

-S3 not associated to the facility.

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3
Document Has Been Signed on 12/16/2022 02:45 PM - It Cannot Be Edited


Created By: Laura Hall On 12/16/2022 at 02:22 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ROSE'S GARDEN ADULT RESIDENTIAL 2
FACILITY NUMBER: 079200599

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/23/2022
Section Cited
CCR
80072(a)(2)

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80072 Personal Rights a) ..., each client shall have personal rights which include...(2) To be accorded safe, healthful and comfortable accommodations... This requirement was not met as evidence by:
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Administrator agreed to implement a written plan that will show how the facility will prevent clients from AWOL. Plan will be submitted to
CCLD by POC date.
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Based on interview and record review the Licensee did not comply with the section cited above in keeping client from AWOL, which poses a potential health and safety risk to persons in care.
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Type B
12/17/2022
Section Cited
CCR80019(e)(1)

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80019 (e) All individuals subject to a criminal record... shall prior to working, residing... in a licensed facility: (1) Obtain a California clearance... as required by the Department... This requirement was not met as evidence by:
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Administrator immediately associated S3 in guardian and submitted LIC9182 and a copy of S3's identification to LPAs. Deficiency cleared during visit.
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Based on interview and record review the Licensee did not comply with the section cited above in having S3 associated to the facility, 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 Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 12/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2022


LIC809 (FAS) - (06/04)
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