435202869-5-30-2025-26-AS-KHOS-DHPL98-20250616083307

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202869
Report Date: 05/30/2025
Date Signed: 05/30/2025 04:54:45 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
01/17/2025 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20250117162513

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: 4	DATE:	05/30/2025
		UNANNOUNCED	TIME BEGAN:	03:39 PM
MET WITH:	Noemi Velasquez		TIME COMPLETED:	04:38 PM

ALLEGATION(S):

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Staff hit resident.
Staff spoke to resident(s) in an inappropriate manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation findings and met with staff Noemi Velasquez (NV).

On 01/17/2025, the Department received a complaint with the allegations that staff hit residents and staff spoke to residents in an inappropriate manner.

On 1/24/2025, the Department conducted an initial investigation visit.

LPA interviewed Administrator, a staff S1, and 2 residents (R1, R2). LPA obtained the physician reports of R1 and R2. LIC500 personnel report, Register of facility residents

Continue on LIC9099-C. Page 1 of 3.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025

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-20250117162513

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: 05/30/2025

NARRATIVE

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Staff hit resident:
Staff spoke to resident(s) in an inappropriate manner:

The allegations are resident hit by staff and staff yelled at resident.

On 1/24/2025, LPA interviewed 2 residents. One resident was unable to answer the questions. The other residents stated there was no staff hit him/her, and no female staff yelled at him/her but a male staff yelled at him/her.

LPA interviewed staff S1. S1 denied he/she hit or physical abused residents. S1 stated some of residents are with bad hearing, so he/she sometimes raised the voice but he/she never yelled at residents. S1 stated he/she did not see or hear any staff hit or yelled residents.

LPA interviewed Administrator (ADM). ADM denied staff hit or yelled at residents. ADM stated he/she did not receive any report that staff hit or yelled at residents. ADM stated some residents with bad hearing, the staff might need to raise voice to talk to them, but were not yelling at the residents.

ADM stated on 12/17/2024, around 1;00PM, resident R1 was transferred from a skilled nursing home to the facility via ambulance. ADM stated R1 was combative and did not want to move in the facility. ADM stated R1's family member and two staff of the ambulance were helping R1 to move in the facility, and were talking loud to R1 because R1 was behaving aggressively. ADM stated neighbors called police department. ADM stated police officers came to the facility but did not leave police report case number.

LPA toured the backyard and side yard, LPA observed the fences are around 2 meters. It was hard to look though the fence to see the inside of the facility. LPA noted that It is easy to hear the voice at the side yard in the neighborhood for the conversation in the facility if windows are opened

On 1/25/2025, LPA interviewed resident R2's family member (FM). FM stated the facility staff treat R2 very good. FM stated R2 received good care from the facility staff. FM stated the facility staff did not yell or hit at R2.

Continue on LIC9099-C. Page 2 of 3.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20250117162513

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: 05/30/2025

NARRATIVE

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On 1/25/2025, LPA called R1's previous skilled nursing home and left message, LPA did not receive any call back.

On 1/25/2025, and 1/27/2025, LPA called resident R1's family member and left message to call back. LPA did not receive any call back.

Based on the review of R1 and R2's physician reports, both have cognitive impairment.

LPA reviewed the facility staff roster, the facility does not have male staff.

Based on the review of R1's physician report, R1 has aggressive behavior and inappropriate behavior.

Based on the interview, observation, and record reviewed, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur.

No citations noted at today’s compliant investigation visit. Exit interview conducted with NV. The report was provided to NV for review and signature. A copy of this report was provided to NV.

Page 3 of 3.,

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 3