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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200967
Report Date: 08/10/2021
Date Signed: 08/31/2021 10:49:02 AM

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: 10DATE:
08/10/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Jocelyn VicenteTIME COMPLETED:
12:55 PM
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Licensing Program Analyst (LPA) conducted an unannounced Case Management - Other visit. The purpose of the visit was to conduct a monthly wellness inspection after a Noncompliance office meeting that was conducted on 7/22/2021. LPA met with the Officer-in-Charge Jocelyn Vicente.

A sign in sheet, thermometer, and hand sanitizer were present at the entrance. There were COVID-19 signs at the throughout the facility to remind staff, residents, and visitors about social distancing and precaution about COVID-19. Hand washing sign was also present at the restroom.

LPA toured the facility. All staff members were observed to be wearing mask. There were visitors with masks visiting resident during tour. The facility was observed to be in sanitary condition.

LPA discussed with the Officer-in-Charge about care plan to caring and supervising resident who is being discharged from the hospital, returning from outings, or simply having a change of condition.

No deficiency cited during visit today.

This report was reviewed with Officer-in-Charge 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: 08/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2021
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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