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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200967
Report Date: 08/08/2024
Date Signed: 08/08/2024 10:44:35 AM


Document Has Been Signed on 08/08/2024 10:44 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 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: 13DATE:
08/08/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Administrator, Michael RoseteTIME COMPLETED:
10:50 AM
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Licensing Program Analysts (LPAs) Simi Rai and Steve Chang arrived to the facility unannounced to conduct a case management visit to follow up on resident (R1) who was admitted after the previous facility was closed due to TSO (Temporary Suspension Order). LPAs met with Administrator, Michael Rosete.

LPAs toured R1's room and observed bed with available bedding, a night stand and functioning lights. LPAs observed a bathroom attached to R1's room which had a working toilet, sink and functioning lights.

LPAs toured the kitchen and pantry closet to observed 2 days of perishable foods and 7 days of nonperishable foods.

LPAs spoke with R1. R1 stated the transition was smooth and there are no issues during and after the transition.

The facility staff is working with R1's responsible party and R1's physicians to obtain the necessary required documents for R1's file. The facility staff is continuing to monitor and assess the resident to ensure the appropriate care and supervision is provided to R1.

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator, Michael Rosete and a copy of the report was provided.

SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2024
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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