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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202869
Report Date: 06/29/2022
Date Signed: 06/29/2022 03:38:08 PM


Document Has Been Signed on 06/29/2022 03:38 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814



FACILITY NAME:ROSE GARDEN ELDERLY CARE LLC, THEFACILITY NUMBER:
435202869
ADMINISTRATOR:LI, TINGXIUFACILITY TYPE:
740
ADDRESS:2993 KNIGHTS BRIDGE RDTELEPHONE:
(408) 809-6806
CITY:SAN JOSESTATE: CAZIP CODE:
95132
CAPACITY:6CENSUS: DATE:
06/29/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:TIME COMPLETED:
02:22 PM
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Facility Type: RCFE
Application Type: CHOFT
Capacity: 6
Census (if any clients in care): 0
Method: Telephone call with CAB
COMP II Participants: Ting Xiu Li, Administrator/Owner; Shannon Betker, analyst, Darla Neeley, CAB manager.

Applicant/administrator participated in COMP II at CAB via telephone call with analyst at CAB. Identification of the applicant and administrator was verified by confirming driver’s license number. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant and administrator were advised to email/fax signed LIC 809 with copy of photo ID to CAB.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Staff qualifications and responsibilities
3. Staff training
4. Applicant and Administrator qualifications
5. Grievances, Complaints, Community resources
6. Food service
7. Medication management
8. Application document review and technical assistance: Pre-licensing inspection
9. Reporting process for unusual incident/Injury
SUPERVISOR'S NAME: Jude De La ConcepcionTELEPHONE: (916) 651-7841
LICENSING EVALUATOR NAME: Shannon BetkerTELEPHONE: (916) 651-3018
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2022
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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