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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202869
Report Date: 01/17/2025
Date Signed: 01/17/2025 12:41:27 PM

Document Has Been Signed on 01/17/2025 12:41 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/
DIRECTOR:		LI, TINGXIUFACILITY TYPE:
740
ADDRESS:2993 KNIGHTS BRIDGE RDTELEPHONE:
(408) 809-6806
CITY:SAN JOSESTATE: CAZIP CODE:
95132
CAPACITY: 6CENSUS: 1DATE:
01/17/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:50 AM
MET WITH:Administrator TingxiuTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter and Marcela Yanez arrived unannounced to open a complaint investigation. During the complaint investigation, a case management deficiencies visit was conducted due to violations discovered during the investigation process. LPA met with Administrator Tingxiu Li.

During investigation, LPAs asked ADM if she notified the Department in writing within five working days of the initiation of hospice care services for any terminally ill resident in the facility or within five working days of admitting a resident already receiving hospice care services. ADM stated she did not.

LPAs reviewed resident R1's Appraisal/Needs and Services plan (ANS), dated December 1, 2024. Based on a review, this ANS does not detail the residents background, or the needs/plan to address the residents needs. This ANS is also not signed by the resident/residents responsible party. ADM stated the resident is on hospice and the hospice nurse did not fill the ANS out.

LPAs discussed with ADM the importance of reporting the initiation of hospice services to Community care licensing. LPA's discussed with ADM, that prior to the resident moving in, the facility must ensure, the residents ANS is filled out and addresses the residents needs, and the facility's plan/object to meet that residents needs.

LPAs discussed PIN 22-24-ASC Collaborating With Home Health Agencies and Hospice Agencies To Provide Care To Residents. LPAs provided CCL flyer for important updates to Dementia Care and Miscellaneous changes.

Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with ADM Tingxiu Li. A Copy of the report was provided, alongside Appeal rights.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2025
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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Document Has Been Signed on 01/17/2025 12:41 PM - It Cannot Be Edited


Created By: Marcela Yanez On 01/17/2025 at 12:10 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 01/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/24/2025
Section Cited
CCR
87632(d)(2)

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87632 Hospice Care Waiver (d)(2) The licensee shall notify the Department... initiation of hospice care services... five working days of admitting a resident already receiving hospice care services...
This requirement was not met as evidenced by;
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ADM stated she will send a letter of understanding regarding the hospice waiver stipualtions, such as notify the Department in writing within five working days of the initiation of hospice care services for any terminally ill resident in the facility or within five working days of ...
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Based on record review and interview, facility ADM stated she did not notifiy the deparment of the initiation of hospice care services for R1. This poses/posed a potential health, safety or personal rights risk to persons in care.
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admitting a resident already receiving hospice care services. The notice shall include the resident's name and date of admission to the facility and the name and address of the hospice.
ADM stated she will send the plan of correction by POC date, 1/24/25.
Type B
01/24/2025
Section Cited
CCR87463(a)

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87463 Reappraisals (a) The pre-admission appraisal, ... shall be updated in writing as frequently as necessary ...to note significant changes in condition,... to keep the appraisal accurate....
This requirement was not met as evidenced by;
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ADM stated she will send a letter of understanding regarding the regulation. ADM stated she will send the plan of correction by POC date, 1/24/25.
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Based on record review , resident R1's Needs and services plan was not filled out. ADM stated the care plan was not filled out because, hospice nurse didn't fill it. This poses/posed a potential health, safety or personal rights risk to persons 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.
SUPERVISOR'S NAME:Romeo Manzano
LICENSING EVALUATOR NAME:Marcela Yanez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2025


LIC809 (FAS) - (06/04)
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