435200967-6-8-2021-26-AS-KHOS-C3TMNE-20210609094525

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435200967
Report Date: 06/08/2021
Date Signed: 06/08/2021 05:45:51 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
01/06/2021 and conducted by Evaluator Yatfai Ng

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20210106141903

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: 10	DATE:	06/08/2021
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Lilette Rosete		TIME COMPLETED:	10:45 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Illegal eviction

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

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 01/15/2021, LPA conducted an unannounced tele-complaint investigation. LPA interviewed 1 staff.

In the morning of 01/06/2021 before the Department received the complaint, LPA received a call from Licensee (S1) inquiring about the process of eviction. S1 stated an eviction was not issued to the resident (R1) and R1 would be accepted back to the facility upon discharged.

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: 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 2

Control Number 26-AS-20210106141903

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

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
26
27
28
29
30
31
32

On 01/14/2021, LPA interviewed the Reporting Party (RP) by phone. RP stated a complaint was filed because RP received information that S1 would not accept R1 back to the facility. RP was unable to reach out to S1 for clarification but later contacted R1’s responsible party and confirmed R1 would be accepted back to the facility after R1 was discharged from a skilled nursing facility.

On 03/23/2021 , medical records reviewed noted R1 was brought to the emergency room on 3/2/21 by the facility. R1 was released back to the facility on 1/20/21 from skilled nursing home. Staff interviewed confirmed that R1 returned to facility on 1/20/21 and was doing well until 3/2/21 when R1 was brought to emergency room for confusion.

This Department has investigated the above allegation. Based on interviews and observation, 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 Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai Ng	TELEPHONE: (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 2