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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202869
Report Date: 01/17/2024
Date Signed: 01/17/2024 04:18:56 PM


Document Has Been Signed on 01/17/2024 04:18 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: 5DATE:
01/17/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Administrator Armando GubaTIME COMPLETED:
04:20 PM
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Licensing Program Analyst (LPA) Manuel Monter arrived to the facility unannounced to conduct a case management visit. LPA met with Administrator (ADM) Armando Guba. LPA explained the purpose of the visit.

LPA interviewed S2. S2 stated ADM started working at the facility on January 15,2024.

LPA interviewed ADM. ADM stated he started working at the facility on January 15, 2024. ADM stated the licensee would be out on leave for two weeks. ADM stated he has been informed of the care the residents need from the licensee. ADM stated he is also read up on their plan of care. ADM stated the licensee left on January 15, 2023, at night. ADM stated he is also an administrator for the facility, Mary's House 2. ADM stated the licensee still handles the finances. ADM stated if he goes shopping, the licensee will Zelle the cost of the items to the ADM. ADM stated he went grocery shopping recently for vegetables on January 16, 2024. ADM stated he will send LPA LIC500 for Rose Garden Elderly Care LLC and Mary house 2.

No deficiencies cited during today's visit. This report was reviewed with Administrator Armando Guba and a copy of the signed report was provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2024
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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