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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610160
Report Date: 08/24/2023
Date Signed: 08/24/2023 11:24:42 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/06/2022 and conducted by Evaluator Evelin Rios
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20221006122914
FACILITY NAME:ROSE SENIOR CARE, INC. #2FACILITY NUMBER:
197610160
ADMINISTRATOR:JEONG, SANDYFACILITY TYPE:
740
ADDRESS:17611 TUBA STREETTELEPHONE:
(818) 217-4955
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY:6CENSUS: 4DATE:
08/24/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Sandy JeongTIME COMPLETED:
11:45 PM
ALLEGATION(S):
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Staff hit resident while in care.
INVESTIGATION FINDINGS:
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On 08/24/2023 Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced subsequent complaint visit for the above allegation. LPA arrived at 9:30 a.m. and was greeted by staff #3 (S3). LPA requested S3 call the administrator. Shortly after LPA met with the administrator Sandy Jeong and explained the reason for the visit. An entrance interview was conducted with Sandy.

At approximately 10:00 a.m. LPA conducted a physical plant tour of the facility. LPA did not observe any health and safety issues. LPA interviewed four (4) residents consisting of residents living in the facility when the allegation was first made and newly admitted residents. LPA interviewed four (4) staff including the administrator. At approximately 10:30 a.m. LPA reviewed and obtained documents relevant to the investigation.

Allegation: Staff hit resident while care.
It is alleged staff #2 (S2) slapped resident #1 (R1). (Continue on to LIC9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023
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 2
Control Number 31-AS-20221006122914
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ROSE SENIOR CARE, INC. #2
FACILITY NUMBER: 197610160
VISIT DATE: 08/24/2023
NARRATIVE
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To investigate this allegation LPA Rios reviewed previous interviews conducted and documents obtained by LPA Martinez on 10/13/2022. Furthermore LPA Rios conducted reinterviews with residents and staff present during the time the allegation was made on today's visit. LPA Martinez interviews with residents on 10/13/2022 and LPA Rios reinterviews with residents on today's visit are consistent and do not corroborate the allegation S1 slapped R1. LPA's interview with S2 revealed S2 denies the allegation. LPA's interview with R1 revealed R1 affirms the allegation did occur. Based on interviews, although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

No deficiencies cited. Exit interview conducted. Copy of report provided.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2