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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202869
Report Date: 08/08/2024
Date Signed: 08/08/2024 12:19:24 PM


Document Has Been Signed on 08/08/2024 12:19 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: 3DATE:
08/08/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Staff, Noemi Velasquez TIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Simi Rai and Steve Chang arrived to the facility unannounced to conduct a case management visit to follow up on resident (R1) who was admitted after the previous facility was closed due to TSO (Temporary Suspension Order). LPAs met with staff (S1) Noemi Velasquez.
LPAs spoke with Licensee/Administrator (ADM) Tingiu Li over the phone and stated the purpose of today's visit. LPAs obtained verbal permission from ADM for S1 to sign today's report on ADM's behalf.

LPAs toured R1's room and observed bed with available bedding, a night stand and functioning lights. LPAs observed a bathroom which had a working toilet, sink and functioning lights.

LPAs toured the kitchen and pantry closet to observed 2 days of perishable foods and 7 days of nonperishable foods.

The facility staff is working with R1's responsible party and R1's physicians to obtain the necessary required documents for R1's file. The facility staff is continuing to monitor and assess the resident to ensure the appropriate care and supervision is provided to R1.

During visit, LPAs observed a bar cart in front of the staff rooms which is located at the entrance of the sun room. The bar cart had over 6 bottles of alcohol which was accessible to residents. Based on review of resident's Physician's Report, resident is diagnosed with dementia. Staff S1 removed the alcohol bottles from the bar cart and placed them in the locked staff room. LPAs spoke with Licensee/Administrator (ADM) Tingiu Li in regards to Title 22 regulations and ADM stated she will ensure the bottles of alcohol are inaccessible to the residents with dementia. ADM agreed and understood.

Deficiencies were cited per California Code of Regulations, Title 22, please see LIC 809-D. LPA Rai spoke with ADM over the phone and conducted an exit interview. This report was reviewed with Staff (S1) Noemi Velasquez and a copy of the report was provided. Appeal Rights were provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2024
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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Document Has Been Signed on 08/08/2024 12:19 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: 08/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/09/2024
Section Cited
CCR
87705(f)(2)

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87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances...
This requirement is not met as evidenced by:
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Licensee/Administrator stated to submit a written plan of action understanding regulation and will ensure alcohol is inaccessble to residents by POC due date. Licensee/Administrator agreed and understood.
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Based on record review and observation, LPAs observed a bar cart infront of staff which had over 6 bottles filled with alcohol and are accessible to residents with dementia which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.
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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 ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2024
LIC809 (FAS) - (06/04)
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