445294201-10-23-2023-26-AS-JJIN-CYW42T-20231226174341

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 445294201
Report Date: 10/23/2023
Date Signed: 10/23/2023 04:47:47 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/04/2023 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20231004145519

FACILITY NAME:	ROSE GARDEN RCH		FACILITY NUMBER:	445294201
ADMINISTRATOR:	ORTIZ, CANDIE		FACILITY TYPE:	740
ADDRESS:	310 HATHAWAY AVENUE		TELEPHONE:	(831) 722-6346
CITY:	WATSONVILLE	STATE: CA	ZIP CODE:	95076
CAPACITY:	6	CENSUS: 5	DATE:	10/23/2023
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Librada (Lee) Ortiz		TIME COMPLETED:	05:15 PM

ALLEGATION(S):

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Facility staff prevent resident from having ice cream
Facility staff yell at residents

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Licensee Librada (Lee) Ortiz.

On 10/04/2023, the Department received a complaint with the above allegations. On 10/11/2023, LPA Marrufo conducted an initial complaint investigation visit and interviewed staff and residents and obtained copied of resident records.

Resident R1’s Identification and Emergency Information Form state R1 is R1’s own responsible person. R1’s Physician’s Report stated that R1 has an allergy to lactose and has a special cardiac diet of low fat, low cholesterol, and no added salt. R1’s Physician’s Report states R1 is able to feed self. R1’s Appraisal/Needs and Services Plan states R1 is mentally able to make his/her own decisions of daily living.

See LIC9099-C for more information. Page 1 of 2.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 26-AS-20231004145519

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 RCH	FACILITY NUMBER: 445294201
	VISIT DATE: 10/23/2023

NARRATIVE

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A witness who was at the facility on 09/29/2023 stated that R1 requested ice cream from staff and a staff yelled at R1 and told R1 he/she cannot have ice cream. The witness stated to have asked the staff if R1 is diabetic and why R1 cannot have ice cream, and the staff stated to not know, but the Licensee Librada (Lee) Najera did not want R1 having ice cream.

During interview on 10/11/2023, R1 stated to have had an incident in which a staff S1 denied R1’s request for ice cream and yelled at R1. R1 stated that the incident was the first time a staff has denied R1’s request for ice cream. R1 stated the staff provide R1 with yogurt upon request. R1 stated to have a lactose allergy and that eating too much ice cream causes R1 to sneeze. R1 stated that S1 yelled at R1 as if R1 were a child.

During interview on 10/11/2023, Licensee/Administrator Candi Ortiz stated that the staff cannot deny R1’s requests for ice cream. Administrator Ortiz also stated that R1 gets diarrhea after having “too much” ice cream and she has communicated to her staff that R1 cannot have ice cream because of the mess R1 makes after having ice cream.

Based on records review and interviews, there is preponderance of evidence to prove the alleged violations did occur. Therefore, the allegations are substantiated.

See 9099-D for deficiencies cited per the California Code of Regulations, Title 22.

This report was reviewed with Licensee Librada (Lee) Ortiz and a copy of the report and appeal rights were provided.

Page 2 of 2.

END REPORT

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20231004145519

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 RCH	FACILITY NUMBER: 445294201
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/23/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/24/2023 Section Cited CCR 87468.1(a)(3)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as	1 2 3 4 5 6 7	Licensee agrees to submit a Plan of Correction by POC date to CCL to train staff to not interfere with the activities of daily living functions of residents, including eating and the food choices of residents.
	8 9 10 11 12 13 14	withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement was not met as evidenced by: Licensee did not ensure that staff S1 did not interfere with R1’s eating, which poses an immediate safety risk to residents in care.	8 9 10 11 12 13 14	The Plan of Correction shall also include plans on offering alternative foods and snacks including lactose free ice cream to residents that do not interfere with the residents’ food allergies. Once training is completed, Licensee agrees to submit training records to CCL.
Type A 10/24/2023 Section Cited CCR 87468.1(a)(1)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff,	1 2 3 4 5 6 7	Licensee agrees to submit a Plan of Correction by POC date to CCL to train staff to accord dignity to residents in their personal relationships with them, including with residents’ request for snacks like ice cream. Once training is completed, Licensee agrees to submit training records to CCL.
	8 9 10 11 12 13 14	residents, and other persons. This requirement was not met as evidenced by: Licensee did not ensure that staff S1 accorded dignity to resident R1 when S1 yelled at R1 to tell R1 that he/she cannot have ice cream.	8 9 10 11 12 13 14

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	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2023

LIC9099 (FAS) - (06/04)

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