<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
435202869
Report Date:
07/31/2024
Date Signed:
07/31/2024 03:23:43 PM
Document Has Been Signed on
07/31/2024 03:23 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, 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:
2
DATE:
07/31/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
09:35 AM
MET WITH:
Tingxiu Li
TIME COMPLETED:
03:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 7/31/2024 at 9:35 a.m. Licensing Program Analysts (LPA) Maria (Mita) Partoza and Manuel Monter arrived and conducted an unannounced required 1 year inspection visit. LPA was greeted by the staff (S1). Licensee/Administrator Tingxiu Li, was not in the facility but arrived at the facility within 10 minutes.
The facility is a Residential Care Facility for the Elderly (RCFE) licensed to serve ages 60 and over 6 non-ambulatory, and a waiver for 2 hospice care. The facility's has 2 residents (R1 to R2) that have neurocognitive impairment. 1 staff were present at the time of the visit. 2 residents were present at the facility and 1 of 2 was in the living room area. LPA observed 1 of 2 residents is in the bedroom and 2 of 2 residents are under hospice care.
At 9:40 a.m. LPA toured the facility inside and outside with ADM, including but not limited to the kitchen, bathroom, dining room, living room, residents rooms, staff room, backyard and walkways. LPA observed the Centralized Complaint and Information Bureau (CCIB) of the CA Department of Social Services (CDSS) on the cork board by the entry way printed on a 8 1/2 x 11 paper it is visible to visitors, resident and staff. The temperature inside the home was at 74 degrees F.
LPAs and ADM toured the 4 bedrooms and LPA observed the rooms to be organized and free from debris and has sufficient storage for resident's personal belongings. 1 of the 4 bedroom is shared. The bathroom inside the shared room is used by other residents. Resident's bedroom has a call alarm system to alert staff if assistance is needed.
Page 1 of 3 see LIC 809C
SUPERVISOR'S NAME:
Romeo Manzano
TELEPHONE:
(650) 388-2297
LICENSING EVALUATOR NAME:
Maria Partoza
TELEPHONE:
(669) 308-3994
LICENSING EVALUATOR SIGNATURE:
DATE:
07/31/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/31/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
(FAS) - (06/04)
Page:
1
of
8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION 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:
07/31/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
During inspection LPAs took photographs what was observed in the kitchen, backyard, foyer, hallway, lounge and bathrooms regarding, chemicals, surveillance camera.
LPAs tested the fire alarm/smoke detector and carbon monoxide and were observed to be in good working condition. The fire extinguisher was last inspected on 6/27/2024.
LPAs requested to review the facility record for the disaster drill training, however ADM stated that he/she does not document the training and did not keep a training log. LPAs reviewed the personnel record and observed that the personnel training was conducted in time.
LPA reviewed 2 of 2 resident centrally stored medication records while cross referencing the medication bottles, resident (R1) had 11 medications that were not listed in the centrally stored medication and destruction record (CSMDR) log. R1 had 1 medication bottle without a label. ADM stated that medication without a label was given by the family. Photograph were taken. Resident (R2) had 9 medication bottles that were not listed in the CSMDR. ADM stated that 7 of 9 medications are no longer prescribed by R2s PCP (primary care physician) and will be removed/destroyed. LPA requested to review R1 and R2's PRN (as needed) log. ADM stated she does not have a PRN log. ADM stated he/she was not aware that he/she had to have a PRN log.
LPA reviewed facility records for 2 staff and 2 residents. LPA reviewed 2 resident medications and centrally stored medication records. LPA conducted interviews with 2 staff and 1 residents.
Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 809-D. A civil penalty is being assessed for the amount of $1000 for a repeat violation.
This report was reviewed with Administrator Tingxiu Li and a copy of the signed report was provided.
Page 3 Out of 3.
END OF REPORT.
SUPERVISOR'S NAME:
Romeo Manzano
TELEPHONE:
(650) 388-2297
LICENSING EVALUATOR NAME:
Maria Partoza
TELEPHONE:
(669) 308-3994
LICENSING EVALUATOR SIGNATURE:
DATE:
07/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/31/2024
LIC809
(FAS) - (06/04)
Page:
7
of
8
Document Has Been Signed on
07/31/2024 03:23 PM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
07/31/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. LPA's observed chemicals ascessible to residents in care in the kitchen, bathroom, Sun Room and backyard. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
08/01/2024
Plan of Correction
1
2
3
4
ADM stated she will send LPA a written plan of action on how she will ensure Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger, are inacessible to residents in care. ADM stated she will send the Plan of correction by POC date, August 1, 2024.
Type A
Section Cited
CCR
87465(h)(4)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above. While reviewing resident R1's medication records and cross referencing the medication bottles, LPA observed a medication container with pills but was not labled. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
08/01/2024
Plan of Correction
1
2
3
4
ADM stated she will send a letter of understanding regarding the regulation, and the importance of ensuring All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. ADM stated she will send the Plan of correction by POC date, August 1, 2024.
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
TELEPHONE:
(650) 388-2297
LICENSING EVALUATOR NAME:
Maria Partoza
TELEPHONE:
(669) 308-3994
LICENSING EVALUATOR SIGNATURE:
DATE:
07/31/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/31/2024
LIC809
(FAS) - (06/04)
Page:
3
of
8
Document Has Been Signed on
07/31/2024 03:23 PM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
07/31/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited. LPAs observed the lower bottom drawer, in the kitchen, had steak knives that were not locked and accessible to residents in care. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
08/01/2024
Plan of Correction
1
2
3
4
ADM stated she will send a written plan of action on how she will ensure knives matches, firearms, tools and other items that could constitute a danger to the resident(s), are inacessible to residents in care. ADM stated she will send the written plan of action to LPA by POC date, 08/01/2024.
Type A
Section Cited
CCR
87465(h)(6)
87465 Incidental Medical and Dental Care (h)(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes:
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above. LPA reviewed 2 Out of 2 resident centrally stored medication records while cross referencing the medication bottles. Resident R1 had 11 medications bottles that were not listed in the centrally stored medication log.Resident R2 had 9 medication bottles that were not listed in the centrally stored medication record. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
08/07/2024
Plan of Correction
1
2
3
4
ADM stated she will send LPA a copy of R1 and R2's centrally stored medication log. ADM stated she will also send a letter of understanding regarding the regulation. ADM stated she will send the plan of correction by POC date, 08/07/2024.
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
TELEPHONE:
(650) 388-2297
LICENSING EVALUATOR NAME:
Maria Partoza
TELEPHONE:
(669) 308-3994
LICENSING EVALUATOR SIGNATURE:
DATE:
07/31/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/31/2024
LIC809
(FAS) - (06/04)
Page:
4
of
8
Document Has Been Signed on
07/31/2024 03:23 PM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
07/31/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(c)
Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. LPA's observed the sun room does not have a slidding screen door. LPA's observed the screen door in the backyard, not attached to the slidding screen door. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/07/2024
Plan of Correction
1
2
3
4
ADM stated she will send photo documentation showing the screen in the sun room has been installed. ADM stated she will send the photo documenation by POC date, 08/07/2024.
Type B
Section Cited
CCR
87465(c)(3)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review and interview, the licensee did not comply with the section cited above. LPA requested to review the PRN log. ADM stated she is not aware that she had to keep a log for PRN medication. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/07/2024
Plan of Correction
1
2
3
4
ADM stated she will create a PRN medication log. ADM stated she will send LPA the form that will record the date and time the PRN medication was taken, the dosage taken, and the resident's response. ADM stated she will also send a letter of understanding regarding the regulation. ADM stated she will send the Plan of correction by POC date, 08/07/2024.
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
TELEPHONE:
(650) 388-2297
LICENSING EVALUATOR NAME:
Maria Partoza
TELEPHONE:
(669) 308-3994
LICENSING EVALUATOR SIGNATURE:
DATE:
07/31/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/31/2024
LIC809
(FAS) - (06/04)
Page:
5
of
8
Document Has Been Signed on
07/31/2024 03:23 PM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
07/31/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview, the licensee did not comply with the section cited above. LPA requested to review the facility disaster drill log. ADM stated she conducted a drill but did not have documenation. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/07/2024
Plan of Correction
1
2
3
4
ADM stated she will conduct a fire drill and send LPA documentaion that a drill has taken place. ADM stated she will send the plan of correction by POC date, 08/07/2024.
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above. Resident R1's physican report is dated July 21, 2023. Resident R2's physicans report is dated March 14, 2023. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/07/2024
Plan of Correction
1
2
3
4
ADM stated she will send LPA a copy of resident R1 and R2's updated physicans report and needs and services plan. ADM stated she will send this to LPA by POC date, 08/07/2024.
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
TELEPHONE:
(650) 388-2297
LICENSING EVALUATOR NAME:
Maria Partoza
TELEPHONE:
(669) 308-3994
LICENSING EVALUATOR SIGNATURE:
DATE:
07/31/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/31/2024
LIC809
(FAS) - (06/04)
Page:
6
of
8
Document Has Been Signed on
07/31/2024 03:23 PM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
07/31/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87405(d)(2)
87405 Administrator Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. (2) Knowledge of and ability to conform to the applicable laws, rules and regulations.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on the totality of today's visit, the licensee did not comply with the section cited above. ADM did not conform to the rules and regulation of the following. ADM did not ensure toxic materials/knives were inacessible to residents in care. ADM stated she did not know that the facility needed to have a PRN log or had to update the residents centrally stored medicatons log. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
08/01/2024
Plan of Correction
1
2
3
4
ADM stated she will send a letter of understanding regarding the regulation. ADM stated she will send the plan of correction by POC date, 08/01/2024.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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
TELEPHONE:
(650) 388-2297
LICENSING EVALUATOR NAME:
Maria Partoza
TELEPHONE:
(669) 308-3994
LICENSING EVALUATOR SIGNATURE:
DATE:
07/31/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/31/2024
LIC809
(FAS) - (06/04)
Page:
8
of
8