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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200967
Report Date: 05/19/2022
Date Signed: 05/19/2022 03:39:24 PM


Document Has Been Signed on 05/19/2022 03:39 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, 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: 8DATE:
05/19/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Michael RoseteTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Christine Dolores conducted an unannounced Case Management - Legal/Non-compliance inspection and met with Administrator, Michael Rosete.

The purpose of the visit is to ensure that facility is adhering to the Compliance Plan submitted to Community Care Licensing (CCL) after a Non-Compliance Conference held on 07/22/21.

Upon entry, LPA was greeted at the door by the Administrator. Facility has a sign-in sheet, thermometer, and hand sanitizer available at entry. LPA toured the facility to include the common areas, resident rooms, and backyard. The facility was in a comfortable temperature and observed to be in sanitary condition. Three out of three staff members were observed wearing a face mask.

LPA discussed with the Administrator the facility's plan to update resident's care plan when resident's are being discharged from the hospital or observed to have a change of condition. LPA reviewed facility staffing schedule and annual training. Staff has a live Dementia training scheduled.

No deficiency cited during today's visit per California Code of Regulations, Title 22.

This report was reviewed with Michael Rosete and a copy of this report was provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 05/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2022
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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