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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202869
Report Date: 12/10/2024
Date Signed: 12/10/2024 12:40:10 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 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
08/18/2023 and conducted by Evaluator Jaime Vado
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20230818160901
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: 3DATE:
12/10/2024
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Staff - Noemi VelasquezTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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- Staff yelled at resident


INVESTIGATION FINDINGS:
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On 12/10/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit to deliver findings regarding the allegation received. LPA met with staff Noemi Velasquez and explained te purpose of today's visit.

During the investigation interviews were conducted and facility observations were made. It's discovered through interviews that there has been witnessed accounts of S1 yelling at a resident. Per interviews the main reason for the yelling has been in regards to facility fees and the non-payment of the fees by R1. Based on the interviews the preponderance of evidence standard has been met. This poses a potential health and safety risk to resident in care. This allegation is substantiated.

Based on LPA interviews and items letters received, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, are being cited on the attached LIC9099D. Report is reviewed with Noemi Velasquez and a copy of this report is provided on this day.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024
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 3
Control Number 26-AS-20230818160901
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: ROSE GARDEN ELDERLY CARE LLC, THE
FACILITY NUMBER: 435202869
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
12/11/2024
Section Cited
CCR
87468.1
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87468.1 Personal Rights of Residents in All Facilities - (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This regulation has not been met as evidenced by:
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The facility shall develop a plan in writing addressing how the facility will address and plan accordingly to abide by this regulation at all times. This plan shall be received by the due date specified.
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Based on the interviews conducted, it was found that S1 has yelled at R1 regarding non-payment of fees. This poses an immediate health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 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
08/18/2023 and conducted by Evaluator Jaime Vado
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20230818160901

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: 3DATE:
12/10/2024
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Staff - Noemi VelasquezTIME COMPLETED:
12:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
- Staff hit resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 12/10/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit to deliver findings regarding the allegation received. LPA met with --- and explained the purpose of today's visit.

During the investigation interviews were conducted and facility observations were made. It's discovered through interviews that it cannot be confirmed that S1 hit a resident based on interviews. This allegation is unsubstantiated as the Department cannot prove or disprove that this allegation took place.

Based on these observations, the above allegations are UNSUBSTANTIATED.
Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are unsubstantiated at this time. Report is reviewed with Noemi Velasquez and a copy of this report is provided on this day.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3