435202869-10-6-2023-26-AS-RMAO-CWFUGN-20231009153436

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202869
Report Date: 10/04/2023
Date Signed: 10/06/2023 10:26:07 AM

Unsubstantiated

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
06/19/2023 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20230619123246

FACILITY NAME:	ROSE GARDEN ELDERLY CARE LLC, THE		FACILITY NUMBER:	435202869
ADMINISTRATOR:	LI, TINGXIU		FACILITY TYPE:	740
ADDRESS:	2993 KNIGHTS BRIDGE RD		TELEPHONE:	(408) 809-6806
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95132
CAPACITY:	6	CENSUS: 3	DATE:	10/04/2023
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	ADM TingXiu Li		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Staff are not meeting resident's dietary needs
Staff are not providing adequate food service to residents
Staff left resident in soiled diaper for an extended period of time

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced complaint investigation to deliver the findings on the above allegations. LPA met with Administrator Tingxiu Li.

Staff are not providing adequate food service to residents/Staff are not meeting resident's dietary needs.

On 06/19/2023 the Department received a complaint alleging staff are not meeting residents’ dietary needs by not providing a variety of food. It has also been alleged staff are not providing adequate food service to residents by not providing sufficient food for residents.

On 06/23/2023, LPA Manuel Monter conducted an unannounced complaint investigation. LPA toured the home and observed the facility food supply. LPA observed sufficient 2-day perishable and 7 day non perishable food supply. LPA observed diabetic food options and sweeteners such as Stevia.
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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20230619123246

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
	VISIT DATE: 10/04/2023

NARRATIVE

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On 06/23/2023, LPA Monter interviewed residents R2-R4. Residents R2 & R3 stated the facility provides residents with enough food and would provide seconds if requested. R3 stated the facility takes into consideration his/her food choices when requested. LPA attempted to interview R4, but resident was nonverbal.

On 06/23/2023 LPA interviewed Staff (S1) regarding the allegations. S1 stated the facility provides many varieties of foods and provides residents with seconds if they want. S1 stated they facility may run low on a few things in grocery day, but the home has never been out of food.

On 06/23/2023 LPA interviewed ADM regarding the allegations. ADM stated the facility was aware of the residents’ dietary restrictions. ADM stated during the time period that R1 was at the facility, the home had only 3 residents. ADM stated only R1 had a special diet due to his/her diabetes. ADM stated the facility does make meals that would meet the residents’ dietary needs such as meals that had less carbs and sugar free. ADM stated the home does have a sample menu, but the home does an active effort to make the food the residents request.

ADM stated she/he would get conflicting food choices from residents’ families such as R1’s family members; one family member would request no carbs such as potatoes and the other family member would complain about the choice. ADM stated in these circumstances that the home would make meals as directed by the resident.

ADM stated the facility provides additional servings if the residents ask. ADM stated there have been instances where a resident is being fed and another resident would insist on being fed as well. ADM stated if a resident requests to be given food, the facility would do so.

On 09/27/2023, LPA Monter interviewed resident R1. R1 stated the home provides enough food for lunch and dinner but did not provide enough food for breakfast. R1 stated the food was not original and all the home would provide him/her was "rice, rice, rice.". R1 stated he/she was not happy with the quality of the food. R1 stated the facility would provide him/her enough food so he/she wasn’t hungry. R1 stated he/she never asked for seconds besides that one time when he/she asked S1 on 06/11/2023, and the staff told him/her they were out of food.
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SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 26-AS-20230619123246

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
	VISIT DATE: 10/04/2023

NARRATIVE

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On 10/04/2023, LPA Manuel Monter conducted an unannounced complaint investigation. LPA toured the home and observed the facility food supply. LPA observed sufficient 2-day perishable and 7-day nonperishable food supply. LPA observed diabetic sweeteners and drink options such as sugar free drinks.

On 10/04/2023, LPA interviewed S1. S1 stated he/she has never told the resident the home was out of food. S1 stated the home made the food that R1 requested while ensuring the food was following the doctors orders for his/her diabetic diet.

On 10/04/2023, LPA interviewed ADM. ADM stated the home does an active effort to make what the residents request. ADM stated for example, R3 does not want vegetables and only prefers certain meals. ADM stated the home makes meals for R3 based on his/her preference. ADM stated the home would change meals that are being provided to R1 based on his/her input. ADM stated R1 would ask for more shrimp in her meals, and the home would make the change to meet the R1's preference while ensuring the home if following her dietary restrictions form the physician. ADM stated R1 once requested turkey with gravy and the home would make the meal he/she requested while making sure its low sugar, low carb, low salt.

A review of R1’s signed admission agreement states R1 will have a special diet if prescribed by a doctor. R1’s admission agreement states R1 has a special diet for her diabetes.

Staff left resident in soiled diaper for an extended period of time

On 06/19/2023 the Department received a complaint alleging staff left a resident soiled diaper on 06/9/2023 at 7:30pm and was changed at 9:30am the following day.

On 06/23/2023 LPA Manuel Monter toured the facility. LPA did not observe any residents who were left soiled during the tour.

On 06/23/2023, LPA Monter interviewed residents R2-R4. Residents R2-R3 stated the facility does assist them with toiletry needs. R3 stated the facility assist with his/her toiletry needs at least 3 times a day. R3 stated the staff would assist him/her with his/her toiletry needs if he/she requested it. LPA attempted to interview R4 but resident was nonverbal.
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SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 26-AS-20230619123246

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
	VISIT DATE: 10/04/2023

NARRATIVE

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On 06/23/2023 LPA interviewed Staff, S1. S1 stated every 2-3 hours they check the residents to see if they need to be changed with undergarments. S1 stated if a resident requested to be changed, S1 would change the residents.

On 06/23/2023, LPA interviewed ADM. ADM stated the facility checks residents every 2-3 hours. ADM stated if a resident asked to be changed, then the staff would oblige and change them. ADM stated when R1’s roommate, R4, was changed or fed, R1 would also request the same. ADM stated when this occurred, the staff would oblige his/her requests.

On 09/27/2023, LPA Monter interviewed R1. R1 stated the facility staff did help him/her but it took a while. R1 stated that he/she would have to wait 30-40 minutes to get changed. LPA asked R1 if he/she was ever left soiled overnight, R1 responded no, never over an hour.

On 10/04/2023, LPA Monter toured the facility. LPA did not observe any residents who were left soiled during the tour.

On 10/04/2023, LPA interviewed ADM. ADM stated it’s a small home and it doesn't take that long to do the rounds and check. We check them every two hours. And for the verbal residents, they will tell us or use their call pendants. ADM stated all the residents have call buttons and if they request to be changed, the facility would comply. ADM stated for non-verbal residents, the facility checks them every two hours. ADM reiterated the home is small and it does not take a long time to do the rounds & check up on the residents during the day or night.

A review of R1’s signed Pre-Placement appraisal and physicians report states R1 needs assistance with using the restroom.

Based on the interviews conducted with residents and staff & records review, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the above allegations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

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SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 4