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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200967
Report Date: 09/07/2021
Date Signed: 09/30/2021 11:15:58 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:
09/07/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Lilette Rosete & Michael RoseteTIME COMPLETED:
02:50 PM
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Licensing Program Analyst (LPA) Yatfai Eric Ng conducted an unannounced infection control site visit. LPA met with the Licensees Lilette Rosete & Michael Rosete.

One central entry point was designated for all staff, residents, and visitors. A temperature screening station, questionnaire, and sign in sheet were present at the entrance.

LPA toured the facility. The facility was observed to be in sanitary condition. All staff members were observed to be wearing masks. There were COVID-19 signs at the entrance and throughout the facility.

LPA inspected 3 restrooms. The restrooms were observed to be adequately stocked with paper towels and hand soap. Hand washing signs were present.

LPA discussed the infection control with Licensees. LPA made recommendations and discussed the current Provider Information Notice PIN 21-40-ASC. 10 out of 10 residents were fully vaccinated per Licensees. All staff present were fully vaccinated also.

An advisory note (LIC 9102) was issued. No deficiency cited during visit.

This report was reviewed with Licensees.

A copy of this report and advisory note were provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai NgTELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2021
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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