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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200967
Report Date: 01/28/2022
Date Signed: 01/28/2022 03:58:49 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:ROSE GARDEN COURTFACILITY NUMBER:
435200967
ADMINISTRATOR:ROSETE, LILETTEFACILITY TYPE:
740
ADDRESS:958 VERMONT STREETTELEPHONE:
(408) 247-0815
CITY:SAN JOSESTATE: CAZIP CODE:
95126
CAPACITY:30CENSUS: DATE:
01/28/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Lilette RoseteTIME COMPLETED:
04:05 PM
NARRATIVE
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Licensing Program Analyst Ryker Heberle (LPA) arrived at the facility approximately 1:50pm to open a complaint investigation. Upon arrival at the facility, LPA confirmed with staff on-site that the facility had a COVID positive resident. LPA spoke with Facility administrators Lilette Rosete and Michael Rosete (Admins) to collect more information on COVID positives at the facility.

Admins confirmed that 1 resident is currently COVID positive at the facility. Admins stated that the facility had its first case of COVID positivity 01/26/2022. Admins clarified that 1 additional resident was sent to the hospital with symptoms of COVID, where they were diagnosed as positive. Resident at the hospital has not yet returned to the facility.

LPA asked Admins whether or not the COVID positives were reported to licensing, Admins stated that the facility had not yet reported the positivity to licensing. An unusual incident report was not submitted within 24 hours of first confirmed positive nor was the regional office called.

Deficiency cited. See 809-D for details. Report was reviewed with Administrator Michael Rosete and a copy of this report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: ROSE GARDEN COURT
FACILITY NUMBER: 435200967
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/04/2022
Section Cited

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80061 - Reporting Requirements - Upon the occurrence... of the events specified... a report shall be made to the licensing agency within the agency's next working day during its normal business hours... (H) Epidemic outbreaks. This requirement was not met as evidenced by:
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Based on observation, the licensee did not comply with the section cited above by not reporting COVID positive residents to licensing, which posed a potential health, safety or personal rights 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: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:
DATE: 01/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2022
LIC809 (FAS) - (06/04)
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