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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405802285
Report Date: 06/11/2025
Date Signed: 06/11/2025 02:06:50 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/04/2025 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20250604141924
FACILITY NAME:ROSE GARDENFACILITY NUMBER:
405802285
ADMINISTRATOR:DIANA BARNHILLFACILITY TYPE:
740
ADDRESS:6100 LOS GATOS ROADTELEPHONE:
(805) 466-2506
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY:6CENSUS: 5DATE:
06/11/2025
UNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Diana Barnhill, AdministratorTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Facility staff used inappropriate restraint on residents for an extended period of time
Licensee does not ensure enough staffing to meet the needs of residents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) De Leon conducted a 10 day Complaint Visit to the facility above. LPA met with Diana Barnhill and explained the purpose of the visit.

LPA De Leon requested the following records: Staff Roster with Telephone numbers, Staff schedule for June 2025, Resident Roster, Resident 1 (R1) LIC. 602A Physicians Report, R1's Physicians order for gait belt, and Appraisal Needs and Services Plan. LPA interviewed staff at 11:45am, 12:00pm and observed 5 residents in the facility.

On the allegation: Facility staff used inappropriate restraint on residents for an extended period of time. LPA interviewed staff which revealed Resident 1 (R1) was tied to the reclining chair with a gate belt for safety due to a recent change in condition, the belt was tied loosely and R1 was able to lift it over R1's head if needed.
Continued 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2025
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 3
Control Number 29-AS-20250604141924
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ROSE GARDEN
FACILITY NUMBER: 405802285
VISIT DATE: 06/11/2025
NARRATIVE
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The facility did not have a doctor's order for a gait belt for R1. LPA interviewed witnesses 1 & 2 (W1)(W2) which revealed while at the facility visiting R1, R1 raised up R1's arms and witnesses noticed a gait belt wrapped around R1's waist and tied to the back of the reclining chair R1 was sitting in. W2 stated they had never been told about a change in condition or the use of a gait belt for R1. Several texts messages were sent back and fourth between Administrator and R1's family regarding the incident. Based on the evidence this allegation is Substantiated at this time.

On the allegation: Licensee does not ensure enough staffing to meet the needs of residents. LPA interviewed Licensee/Administrator regarding the staffing needed for R1. R1 had a recent change in condition and sun downing was becoming an issue for R1. The change in condition was reported to R1's physician and Administrator is getting an up to date LIC 602A physicians report for the change, and will update the appraisal needs and services plan accordingly. Administrator stated R1 does need additional staffing during sun downing from 3pm-7pm or 4pm-8pm. Administrator plans to do a two day rate increase for the change in condition and to provide a staffing 1 on 1 to R1 during sun dowing to keep R1 safe. Administrator said the facility has hired 3 new staff in February 2025 but all 3 staff are no longer working, the administrator is currently hiring for caregivers and hired 2 new caregivers yesterday, once trained the staff will be added to the schedules. Based on the evidence this allegation is Substantiated at this time.

Exit interview conducted, deficiencies cited, copy of report and appeal rights printed for Administrator/Licensee.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20250604141924
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ROSE GARDEN
FACILITY NUMBER: 405802285
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/12/2025
Section Cited
CCR
87608(a)(1)
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(a)...(1)Postural supports shall be limited to appliances...soft ties, used to achieve proper body position and balance,..or to position rather than restrict movement including, but not limited to, preventing a resident from falling out of bed, a chair, etc. This requirment was not met as evidenced by:
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Administrator will not use any ties or gait belt with R1, get updated LIC 602A & Apprisal Needs and Services plan for R1 and train staff in Regulation 87608, provide proof of trianing and requested records to CCL by 06/12/2025.
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Based on interviews the Licensee did not comply with the regualtion above Administrator used a gait belt to tie a resident to reclining chair which poses an immediate Health, Safety and Personal rights risk to reisdnets in care.
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Type B
06/18/2025
Section Cited
CCR
87411(a)
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(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...This requirement was not met as evidenced by:
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Administrator agreed to higher more staff and provide a up to date LIC 500 for current staffing working at the facility, Administrator also will do a care increase to account for a 1 on 1 for R1 while sun downing, and review regulation 87411 and provide written letter of understanding to CCL by 06/18/2025.
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Based on interviews the Licensee did not comply with the regulation above, the facility will need additional staffing to take care of R1 due to change in condition and meeting R1's needs which posses a potential Health, Safety and Personnel rights risk to residents 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: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2025
LIC9099 (FAS) - (06/04)
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