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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202869
Report Date: 08/16/2024
Date Signed: 08/16/2024 10:44:52 AM


Document Has Been Signed on 08/16/2024 10:44 AM - 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:
08/16/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:TingXiu Li - Licensee/AdministratorTIME COMPLETED:
10:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced case management - deficiencies visit and to amend the annual required inspection that was conducted on July 31, 2024. LPA met with licensee/administrator (LIC/ADM) TingXiu Li and stated the purpose of the visit.

LPAs toured the facility inside and out including 4 resident bedrooms, two restrooms, kitchen, living room, dinning room, and backyard. LPA observed 3 of 3 residents were in their bedroom resting. LPA observed no toxic, chemicals or knives during today's visit that are accessible to residents. The screen door in the sun room was repaired and working properly.

LPA toured the kitchen and pantry closet to observed 2 days of perishable foods and 7 days of nonperishable foods. LPA observed no obstructions on the walkways and hallways, exits were free from obstruction. Alcoholic beverages were in a locked container and all medications are in a locked cabinet.

LPA reviewed the Centrally Stored Medication and Destruction Record (CSMDR) and observed that list of medication are listed on the CSMDR. LPA reviewed the appraisal needs and services plan (LIC 625) of 2 of 2 residents and observed that it was completed by LIC/ADM.

LPA amended a repeat violation that was assessed incorrectly on 7/31/2024.

No deficiency was cited during today's visit based on California Code of Regulations (CCR) Title 22. An exit interview was conducted with LIC/ADM TingXiu Li. A copy of today's report, amended citation and appeal's right was provided to the licensee.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria PartozaTELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2024
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 08/16/2024 10:44 AM - 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: 08/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/17/2024
Section Cited
CCR
87309(a)

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(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:
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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 8/17/24.
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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.
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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: Maria PartozaTELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2024
LIC809 (FAS) - (06/04)
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