<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200967
Report Date: 11/15/2022
Date Signed: 11/15/2022 05:03:35 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 11/15/2022 05:03 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: 18DATE:
11/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:19 PM
MET WITH:Lilette Rosete and Michael RoseteTIME COMPLETED:
02:08 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Administrator (ADMs) Lilette Rosete and Michael Rosete. Upon arrival, ADM took LPA body temperature, asked the infection control questionnaires, and checked LPA in the visitor log book.

LPA toured the facility inside and out with ADM. COVID posters were observed at main entrance. Screening station with masks, hand sanitizer, thermometer and visitor log book was observed at the main entrance. Living room, kitchen, dinning room, hallway and two restrooms were inspected. Some trash cans were observed without covers in restrooms and in common area. ADM stated ADM will put all the trash cans with covers in the facility within 5 days. Paper towels were observed with holders. One of the restrooms was observed without the posters of washing hands for 20 seconds. ADM stated ADM will put the posters of washing hands for 20 seconds in the restrooms in 5 days. 17 resident bedrooms, and laundry room were inspected. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. PPE supplies were observed sufficient. Medication closet, knives closet, and cleaning product closet were observed locked.

Fire extinguisher was serviced on 03/24/2022. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways.

ADM stated all the residents and staff are fully vaccinated and done with booster. ADM stated the facility already submitted the Infection Control Plan to CCL office. No citation were noted today. Exit interview was conducted with ADM. This report was provided to ADM for signature.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2022
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 1