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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202869
Report Date: 01/17/2025
Date Signed: 01/17/2025 12:41:27 PM

Document Has Been Signed on 01/17/2025 12:41 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/
DIRECTOR:		LI, TINGXIUFACILITY TYPE:
740
ADDRESS:2993 KNIGHTS BRIDGE RDTELEPHONE:
(408) 809-6806
CITY:SAN JOSESTATE: CAZIP CODE:
95132
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 1DATE:
01/17/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:50 AM
MET WITH:Administrator TingxiuTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter and Marcela Yanez arrived unannounced to open a complaint investigation. During the complaint investigation, a case management deficiencies visit was conducted due to violations discovered during the investigation process. LPA met with Administrator Tingxiu Li.

During investigation, LPAs asked ADM if she notified the Department in writing within five working days of the initiation of hospice care services for any terminally ill resident in the facility or within five working days of admitting a resident already receiving hospice care services. ADM stated she did not.

LPAs reviewed resident R1's Appraisal/Needs and Services plan (ANS), dated December 1, 2024. Based on a review, this ANS does not detail the residents background, or the needs/plan to address the residents needs. This ANS is also not signed by the resident/residents responsible party. ADM stated the resident is on hospice and the hospice nurse did not fill the ANS out.

LPAs discussed with ADM the importance of reporting the initiation of hospice services to Community care licensing. LPA's discussed with ADM, that prior to the resident moving in, the facility must ensure, the residents ANS is filled out and addresses the residents needs, and the facility's plan/object to meet that residents needs.

LPAs discussed PIN 22-24-ASC Collaborating With Home Health Agencies and Hospice Agencies To Provide Care To Residents. LPAs provided CCL flyer for important updates to Dementia Care and Miscellaneous changes.

Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with ADM Tingxiu Li. A Copy of the report was provided, alongside Appeal rights.
Romeo ManzanoTELEPHONE: (650) 388-2297
Marcela YanezTELEPHONE: (279) 789-1062
DATE: 01/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2025
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 01/17/2025 12:41 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: 01/17/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
87632 Hospice Care Waiver (d)(2) The licensee shall notify the Department... initiation of hospice care services... five working days of admitting a resident already receiving hospice care services...
This requirement was not met as evidenced by;
Deficient Practice Statement
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POC Due Date: 01/24/2025
Plan of Correction
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ADM stated she will send a letter of understanding regarding the hospice waiver stipualtions, such as notify the Department in writing within five working days of the initiation of hospice care services for any terminally ill resident in the facility or within five working days of ...
Section Cited
Deficient Practice Statement
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POC Due Date:
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.
Romeo ManzanoTELEPHONE: (650) 388-2297
Marcela YanezTELEPHONE: (279) 789-1062

DATE: 01/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2025

LIC809 (FAS) - (06/04)
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