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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435200967
Report Date: 06/08/2021
Date Signed: 06/08/2021 05:34:52 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
03/09/2021 and conducted by Evaluator Yatfai Ng
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20210309134341
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: 10DATE:
06/08/2021
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Lilette RoseteTIME COMPLETED:
11:35 AM
ALLEGATION(S):
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Caregiver in facility had sexual relations with resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Yatfai Eric Ng conducted a subsequent unannounced investigation visit to deliver complaint finding. LPA met with the Licensee Lilette Rosete.

On 3/10/2021, LPA conducted an unannounced initial investigation visit. LPA interviewed 1 staff.

Between 3/11/2021 and 5/4/2021, the Department interviewed 6 staff, 1 resident (R1) who was the alleged victim, and 1 R1’s relative . The Department also reviewed R1’s medical notes.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai NgTELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 7
Control Number 26-AS-20210309134341
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: 06/08/2021
NARRATIVE
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6 out of 6 staff interviewed denied seeing, hearing, or witnessing a caregiver had sexual relations with resident. 3 out 6 staff pointed out that R1 used to have a roommate who was alert and oriented, the roommate did not complain any misconduct between caregiver and R1.

R1’s relative was interviewed and did not have proof, evidence, or confidence on the identity of the alleged staff as it was based on hearsay. R1 denied having sexual relations with any staff while in care in the facility

This Department has investigated the above allegation. Based on interviews, the Department found that the above allegation is UNSUBSTANTIATED. Unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegation did or did not occur.

This report was reviewed with Licensee and a copy of this report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai NgTELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 7
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
03/09/2021 and conducted by Evaluator Yatfai Ng
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20210309134341

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: 10DATE:
06/08/2021
ANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Lilette RoseteTIME COMPLETED:
11:35 AM
ALLEGATION(S):
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Resident sustained a fracture while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Yatfai Eric Ng conducted a subsequent unannounced investigation visit to deliver complaint finding. LPA met with the Licensee Lilette Rosete.

On 3/10/2021, LPA conducted an unannounced initial investigation visit. LPA interviewed 1 staff.

Between 3/11/2021 and 5/4/2021, the Department interviewed 6 staff, 1 resident (R1) who was the alleged victim, and 1 R1’s relative. The Department also reviewed R1’s medical notes and files.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai NgTELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 26-AS-20210309134341
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: 06/08/2021
NARRATIVE
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R1’s medical discharge note dated on 3/6/2021 revealed that R1 was admitted on 3/2/2021 for confusion and discharged on 3/6/21 with diagnosis of confusion due to delirium and was oriented x1 on discharged. X-ray showed left femur fracture and R1 underwent surgery and was discharged to SNF on 3/15/21. The review of R1’s needs and services plan noted that R1 is a total assist for using commode, incontinence, and toileting and requires Hoyer lift for transfer.

4 out of 6 staff stated they were aware R1 was confused when R1 returned from hospital on 3/6/2021. 2 out of 2 staff who assisted R1 on the commode on 3/6/2021 were aware that R1 was confused but still left R1 unattended on the commode citing R1 preferred privacy.

R1’s interview did not confirm that R1 requested to be left alone while on commode on 3/6/21.

Based on record review, and interviews, the preponderance of evidence standard has been met; therefore, the allegation is found to be SUBSTANTIATED, which means that the allegation did occur.

A deficiency was cited during visit. See LIC 9099-D. An immediate civil penalty in the amount of $500 was assessed today. Additional civil penalty in the amount of $10,000 for the violation resulting in serious bodily injury is pending review.

This report was reviewed with Licensee and a copy of this report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai NgTELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2021
LIC9099 (FAS) - (06/04)
Page: 7 of 7
Control Number 26-AS-20210309134341
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/09/2021
Section Cited
CCR
87468.2(a)(4)
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87468.2(a)(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by: based on record review, R1 was diagnosed with confusion when
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Licensee agrees to conduct training on staff regarding residents’ safety.

Licensee is to submit the training record to LPA via email by the due date.
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discharged from hospital to the facility and R1 needs full assistance in toileting per care plan. Based on interviews, 2 out of 2 staff who assisted R1 were aware of R1’s confusion mental status. However, R1 was still left unattended resulting in R1 sustaining hip fracture due to the fall.
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An immediate civil penalty in the amount of $500 was assessed today. Civil penalty in the amount of $10,000 for violation resulting in serious bodily injury is pending review.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai NgTELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 7