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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202869
Report Date: 01/31/2025
Date Signed: 01/31/2025 03:43:41 PM

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
01/10/2025 and conducted by Evaluator Manuel Monter
COMPLAINT CONTROL NUMBER: 26-AS-20250110122127
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:
01/31/2025
UNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Staff Noemi VelasquezTIME COMPLETED:
03:50 PM
ALLEGATION(S):
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Staff left a resident soiled for an extended period of time.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Manuel Monter & Kenneth Madrigal conducted an unannounced complaint inspection to deliver the findings on the above allegation. LPA met with Staff Noemi Velasquez.

On January 10, 2025, the Department received a complaint alleging Staff left a resident soiled for an extended period of time. It has been alleged that resident R1 was left soiled for an extended period of time.

On January 14 & 15, 2025, LPA Monter interviewed Witness W1 and W2. W1 stated he/she has been to the facility on 3 different occasions. W1 stated he/she witnessed resident R1 in a soiled state with a strong odor, on January 5th, 2025. W1 stated he/she informed facility staff of R1’s soiled state and staff changed the resident. W1 stated he/she did not note R1 in a soiled state the other 2 times he/she visited R1 at the facility. W2 stated he/she visits the facility at least 2 times a week. W2 stated he/she has never observed R1 unchanged or his/her bedding in a soiled state.
Page 1 Out of 3.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2025
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-20250110122127
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: 01/31/2025
NARRATIVE
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On January 17, 2025, LPA’s conducted an unannounced complaint investigation visit. LPA Manuel Monter and Marcela Yanez interviewed ADM Tingziu Li. ADM stated her staff are instructed to check residents every 2 hours, to see if they are soiled. ADM stated if residents are observed soiled, then staff will change them. ADM stated she has never observed residents left in a soiled state.

LPA Manuel Monter and Marcela Yanez interviewed resident R2. R2 stated the staff does check up on him/her. R2 stated the staff does assist him/her with changing and using the restroom. R2 stated he/she hasn’t seen other residents in a soiled or in a disheveled. The Department was unable to interview resident R1, who no longer lives at the facility.

On January 22, 2025, LPA Monter interviewed Witness W3. W3 stated he/she visits the facility everyday, multiple times a day. W3 stated, on an unspecified date, he/she observed resident R1 with a soiled diaper. W3 stated he/she asked staff S1 to change resident R1, but W3 , S1 told him/her that he/she would not change R1 because the home health aide was arriving at the facility soon. W3 stated he/she left the facility 15 minutes later, and the home health aide did not arrive by the time W3 left the facility.

On January 27, 2025, LPA Monter interviewed Witness W4 & W5. W4 stated he/she only visited the facility on 2 occasions. W4 stated he/she has not observed resident R1 in a soiled state or his/her bedding in a soiled state or with odor.

W5 stated he/she visited the facility initially 3x a week, which increased to 5x a week. W5 stated there was 3 instances (December 27th 2024, January 6 & 8 2025), where he/she found R1 in a soiled state, but stated he/she was unsure how long R1 was left soiled. W5 stated he/she didn't inform facility staff or ADM that he/she found R1 in a soiled state.

On January 31, 2025, Licensing Program Analyst Manuel Monter interviewed staff S1. S1 stated, he/she checks the residents every 2 hours. S1 stated he/she will change the residents if he/she observes them soiled or if family members inform him/her that a resident is soiled. S1 stated he/she has never left a resident soiled and stated he/she ensure the residents sheets are changed if soiled as well.

Page 2 Out of 3.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 26-AS-20250110122127
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: 01/31/2025
NARRATIVE
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On January 17 and 31, 2025, LPA toured the facility inside and out. LPAs did not observe any residents that were unhygienic / dirty or unkempt. LPA’s did not observe any bedding with stains or odor during visit.

Based on the interviews conducted & 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

This report was reviewed with ADM Tingxiu Li via phone call. ADM stated Staff Noemi Velasquez could sign on her behalf. A copy of the report was provided.

Page 3 Out of 3. END OF REPORT.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3