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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200967
Report Date: 11/15/2022
Date Signed: 11/15/2022 05:04:36 PM


Document Has Been Signed on 11/15/2022 05:04 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:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
02:09 PM
MET WITH:Lilette Rosete and Michael RoseteTIME COMPLETED:
03:02 PM
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On 08/09/2022, Licensing Program Analyst (LPA) Steve Chang conducted an unannounced Case Management - Legal/Non-compliance inspection and met with Administrator (ADMs) Michael Rosete and Licensee Lilette 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.

LPA toured the facility with ADM to include the common areas, resident rooms, and backyard. The facility was in a comfortable temperature and observed to be clean and maintained. All of the staff observed to be wearing a face mask.

LPA discussed with ADM regarding 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.

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

This report was reviewed with Licensee Lilette Rosete and a copy of this report was provided.
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)
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