435200967-10-27-2020-26-AS-KHOS-BUUJ8K-20201029064937

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435200967
Report Date: 10/27/2020
Date Signed: 10/27/2020 04:04:43 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/31/2020 and conducted by Evaluator Yatfai Ng

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20200331171357

FACILITY NAME:	ROSE GARDEN COURT		FACILITY NUMBER:	435200967
ADMINISTRATOR:	ROSETE, LILETTE		FACILITY TYPE:	740
ADDRESS:	958 VERMONT STREET		TELEPHONE:	(408) 247-0815
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95126
CAPACITY:	30	CENSUS: 19	DATE:	10/27/2020
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Lilette Rosete		TIME COMPLETED:	11:40 AM

ALLEGATION(S):

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Staff sexually abused resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Yatfai Eric Ng conducted an unannounced subsequent investigation tele-visit today to deliver a complaint finding. Due to current COVID-19 situation, LPA virtually met with the Licensee Lilette Rosete.

On 4/7/2020, LPA conducted an unannounced initial investigation visit. LPA virtually toured the facility and obtained a copy of Resident Appraisal (LIC 603A), a copy of Physicians Report for Residential Care Facilities for the Elderly (LIC 602A), Admission Agreements for Residential Care for the Elderly (LIC 604A), and staff rosters.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai Ng	TELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20200331171357

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 10/27/2020

NARRATIVE

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Between 7/28/2020 and 8/31/2020, the Department interviewed 5 staff and the alleged victim (AV). 5 out of 5 staff stated they did not witness other staff sexually abused resident while in care. All staff stated there are always two staff who assist the AV with cleaning after toileting. On the day of incident when AV accused staff (S1), there was another staff (S2) who was present. S2 believed S1 might have unintentionally been too rough while cleaning AV. But S2 remembered that prior to cleaning AV, S1 told AV he would be cleaning her private parts as this was normal staff procedure. Licensee confirmed that both staff told her about the incident. Upon knowledge, licensee no longer had S1 assisting with cleaning AV. S1 no longer worked at the facility shortly after. AV stated after she complained to licensee, S1 was no longer allowed to assist her. AV said she felt safe at the facility and had no issue with the male or female caregivers.

Based on record review, LIC 602A of the AV revealed that AV did not have dementia.

Based on interviews and record review, the Department has determined that the allegation was UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

This report was reviewed with Licensee and a copy of this report was emailed to Licensee for reference and to obtain a signature.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai Ng	TELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2020

LIC9099 (FAS) - (06/04)

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