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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202869
Report Date: 08/25/2023
Date Signed: 08/25/2023 04:58:52 PM

Document Has Been Signed on 08/25/2023 04:58 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:
08/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Tingxiu LiTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility annual inspection. LPA met with Licensee / Administrator (ADM), Tingxiu Li.

During visit, LPA toured the facility with ADM to include the living room, kitchen, garage, backyard, resident bedrooms, and bathrooms. Facility temperature maintained at 77 degrees Fahrenheit.

The facility has at least 2 days worth of perishables and 7 days worth of non-perishable foods. LPA observed items in the kitchen refrigerator were not labeled. ADM stated the non-labeled foods are for staff. ADM states to have another refrigerator and freezer located in the garage. LPA recommended to separate the resident and staff food. ADM stated understanding. The kitchen's refrigerator was maintained at 40 degrees Fahrenheit and freezer maintained at 0 degreed Fahrenheit.

In the kitchen area, LPA observed the disinfectants, medications, and sharp objects were not properly locked and secured. LPA observed the cabinets and drawers contain a device to secure the items, however, the device was not being used at that time. Staff attempted to place the device back on the cabinets, however, LPA was still easily able to open the cabinet and drawers. ADM states to buy a new lock for the drawers and cabinets.

LPA observed a foul odor of rotten food in the kitchen area. LPA observed 3 out of 3 facility trash bins were completely full. Staff immediately threw out the trash. LPA observed dirty trash bags along the fence of the facility. ADM states to have placed an order for a larger trash bin but the bin has not been delivered yet. LPA also observed dirty wipes an gloves next to the trash bin outside. LPA observed the garage refrigerator / freezer was dirty with dried food items. ADM states some items in the freezer are for residents and the refrigerator items were for ADM. SEE LIC809-C.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 08/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/25/2023
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 11
Document Has Been Signed on 08/25/2023 04:58 PM - It Cannot Be Edited


Created By: Christine Dolores On 08/25/2023 at 02:56 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 08/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type A
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview the licensee did not comply with the section cited above due to full trash bins which caused the facility to have a foul odor, dirty refridgerator / freezer in the garage and dirty piles of wipes in the backyard which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/26/2023
Plan of Correction
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Licensee states to ensure the facility will be kept clean and sanitary at all time. Licensee will send a picture of the clean fridge and clean trash area to LPA Dolores via email by POC due date.
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review the facility's hot water temperature was maintained at 150 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/26/2023
Plan of Correction
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Licensee will turn down the hot water temperature. Licensee will submit a picture of the hot water temperature to LPA Dolores via email by POC due date.
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:Sarah Yip
LICENSING EVALUATOR NAME:Christine Dolores
LICENSING EVALUATOR SIGNATURE:
DATE: 08/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2023


LIC809 (FAS) - (06/04)
Page: 2 of 11
Document Has Been Signed on 08/25/2023 04:58 PM - It Cannot Be Edited


Created By: Christine Dolores On 08/25/2023 at 02:56 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 08/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
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
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Based observation and interview the licensee did not ensure disinfectants and cleaning solutions in the kitchen and closet were stored where inaccessible to clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/26/2023
Plan of Correction
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Licensee will purchase new locks tonight. Licensee will install the locks and send a picture to LPA Dolores via email by POC due date.
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review the licensee did not ensure staff were provided CPR and first aid certification which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/26/2023
Plan of Correction
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Licensee will send staff for CPR / first aid training. Licensee will send the training confirmation schedule to LPA Dolores by POC due date.
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:Sarah Yip
LICENSING EVALUATOR NAME:Christine Dolores
LICENSING EVALUATOR SIGNATURE:
DATE: 08/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2023


LIC809 (FAS) - (06/04)
Page: 3 of 11
Document Has Been Signed on 08/25/2023 04:58 PM - It Cannot Be Edited


Created By: Christine Dolores On 08/25/2023 at 02:56 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 08/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87467(a)
Resident Participation in Decisionmaking
(a) Prior to, or within two weeks of the resident's admission, the licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident's preferences regarding the services provided at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review the licensee did not ensure to develop an appraisal/needs and services plan for 5 out of 5 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/01/2023
Plan of Correction
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Licensee will develop an appraisal/needs and services plan for 5 out of 5 residents. Licensee will submit 5 out of 5 resident's appraisal/needs and services plan to LPA Dolores by POC due date.
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
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Based on observation, interview, and record review the licensee did not ensure staff were provided a evacuation drill which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/26/2023
Plan of Correction
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Licensee will train staff on emergency scenarios and evacuation drills. Licensee will submit the training record to LPA Dolores by POC due date.
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:Sarah Yip
LICENSING EVALUATOR NAME:Christine Dolores
LICENSING EVALUATOR SIGNATURE:
DATE: 08/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2023


LIC809 (FAS) - (06/04)
Page: 4 of 11
Document Has Been Signed on 08/25/2023 04:58 PM - It Cannot Be Edited


Created By: Christine Dolores On 08/25/2023 at 03:42 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 08/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type A
Section Cited
CCR
1569.696(a)
(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review 3 out of 5 residents used half bed rails and 2 out of 5 residents use full length bedrails which the staff are not trained on the use of postural supports which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/26/2023
Plan of Correction
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Request Denied
Type A
Section Cited
CCR
87465(h)(1)(2)
(h) The following requirements shall apply to medications which are centrally stored: (1) Medications shall be centrally stored under the following circumstances: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview the licensee did not ensure the centrally stored medications were kept in a safe and locked place that an not accessible to persons other than employees responsible for supervision which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/26/2023
Plan of Correction
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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:Sarah Yip
LICENSING EVALUATOR NAME:Christine Dolores
LICENSING EVALUATOR SIGNATURE:
DATE: 08/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2023


LIC809 (FAS) - (06/04)
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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: 08/25/2023
NARRATIVE
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Resident bedrooms contained hospital beds, night stands, adequate lighting, linens, and a chair. 3 out of 5 resident bedrooms contained half bed rails. ADM was unable to provide the physician's order for the half bed rails. 2 out of 5 residents has full length bed rails which is addressed in the hospice care plan.

Bathrooms contained accessible hygiene products, lidded trash bin, and paper supplies. ADM states none of the residents are at risk if directly exposed to hygiene products. Hot water temperature measured at 150 degrees Fahrenheit. ADM was advised.

LPA reviewed 5 resident file contained a signed admission agreement, physician's report, TB result, emergency contact information, safeguard of personal property and valuables, personal rights, and pre-placement appraisal. R1 - R5's file did not contain an appraisal/needs and services plan and centrally stored medication record (CSMR). The facility has a list of the residents medications but does not contain all the information listed on the CSMR.

LPA reviewed 2 resident files contain a background clearance, personnel report, health screening, TB result, and criminal record statement. 2 staff and the ADM does not have an active CPR and 1st Aid Certification.

The facility has the facility license posted at the front door, along with the resident's personal rights, resident council, hospice waiver, and emergency disaster plan.

LPA interviewed 2 residents and 1 staff members.

During visit, LPA obtained the facility's personnel record.

Deficiencies are being cited per California Code of Regulations, Title 22. This report was reviewed with Licensee / Administrator (ADM), Tingxiu Li and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023
LIC809 (FAS) - (06/04)
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