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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200967
Report Date: 07/22/2021
Date Signed: 08/10/2021 12:09:27 PM

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: 11DATE:
07/22/2021
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Lilette Rosete, Michael Rosete, Jacob ReinhardtTIME COMPLETED:
01:40 PM
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A Noncompliance meeting was conducted virtually today via Teams Meeting. Present at the meeting were San Bruno Adult and Senior Care Regional Manager Vivien Helbling, Licensing Program Manager Sarah Yip, Licensing Program Analyst Yatfai Eric Ng, and facility representatives Lilette Rosete, Michael Rosete, and attorney Jacob Reinhardt.

The purpose of the noncompliance meeting was to discuss the serious violation at the facility on 03/06/2021 which resulted in a serious bodily injury of a resident. Substantiated complaint findings were delivered on 06/08/2021 and deficiency was cited for violations of Title 22 California Code of Regulations:

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (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. A resident sustained a hip fracture while in care, due to neglect/lack of supervision.

Facility representatives were informed during non-compliance meeting that additional civil penalties in the amount of $10,000 may be assessed pending review for serious violation resulting in serious bodily injury. Noncompliance Conference Summary LIC 9111 and a compliance plan were established during the meeting.

Report was reviewed with representatives. A copy of this report, LIC 9111, and link resources were provided to Licensee for signature via email.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai NgTELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021
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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