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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202869
Report Date: 07/06/2022
Date Signed: 07/06/2022 05:02:11 PM


Document Has Been Signed on 07/06/2022 05:02 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131



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: 0DATE:
07/06/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Tingxiu LiTIME COMPLETED:
05:03 PM
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Licensing Program Analyst Ryker Heberle (LPA) conducted an announced pre-licensing inspection today. LPA met with Administrator Tingxiu Li (Admin).

At 03:01pm, LPA toured the facility inside and out. Including living room, dining room, kitchen, sun room, 4 bedrooms, 2 bathrooms, and garage.

The facility is equipped with connected smoke detectors. The smoke detector located in the dining room was tested and observed to be working and operations. Fire extinguisher was observed in the dining room and had been purchased on May 15th, 2022. The kitchen, dining room, living room, and family room were observed in good repair. Facility does not currently have any residents or staff members aside from licensee.

Resident bedrooms were observed in good repair, furnished, with clean linens and adequate lighting. Bathrooms were observed clean and in working order with non-skid mats and grab bars. The water temperature was measured at 96.1 *F in facility bathroom. Admin adjusted the water heater to warmer levels, and will supply LPA proof of proper temperature once the water finishes heating. Centrally stored medication cabinet was observed. 2 days supply of perishable and 1 weeks supply of nonperishable food was observed. A complete first aid kit was inspected. LPA observed facility backyard and fences to be in good repair. All outdoor and indoor passageways were observed clear and free of obstruction. No bodies of water observed.

Component III orientation was waived based on Admin's experience. Based on today's inspection, the physical plant is recommended for licensure pending creation of emergency key set, obtaining of liability insurance, and adjustment of water temperature to levels between 105*F and 120*F. Exit interview conducted with and copy of report provided to Administrator Tingxiu Li
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:
DATE: 07/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2022
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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