<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 445294201
Report Date: 02/16/2024
Date Signed: 02/16/2024 05:06:43 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
11/03/2023 and conducted by Evaluator David Marrufo
COMPLAINT CONTROL NUMBER: 26-AS-20231103161848
FACILITY NAME:ROSE GARDEN RCHFACILITY NUMBER:
445294201
ADMINISTRATOR:ROGERS, CANDIEFACILITY TYPE:
740
ADDRESS:310 HATHAWAY AVENUETELEPHONE:
(831) 722-6346
CITY:WATSONVILLESTATE: CAZIP CODE:
95076
CAPACITY:6CENSUS: 4DATE:
02/16/2024
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Candie OrtizTIME COMPLETED:
05:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff mismanaged residents medication.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Administrator Candie Ortiz.

On 11/03/2023, the Department received a complaint with the above allegation. On 11/08/2023, an initial complaint investigation visit was conducted and on 12/09/2023, an additional complaint investigation visit was conducted. During the investigation process, 4 out of 4 residents were interviewed, 3 family members of residents were interviewed, 1 resident family member was attempted to be interviewed, but could not be reached, and 1 out of 2 co-licensees were interviewed.

See LIC9099-C for more information. Page 1 of 2.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2024
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 6
Control Number 26-AS-20231103161848
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: 02/16/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
On 12/09/2023, LPA Marrufo and LPM Jackie Jin conducted a review of medications and medication records at the facility. During medications review, R1 had a PRN (taken as needed) medication but did not have a PRN log. R2 had a medication that should have 340 pills remaining, but there were 346 pills remaining. R3 had a medication that should have had 15 pills left but had 20 and another medication that should have had 53 pills remaining but had 41. R3 also had a medication that was a PRN but did not have a PRN log. During records review, Administrator Candie Ortiz stated to not have a PRN medications log.

R1’s Physician’s Report states that R1 is not able to administer his/her own PRN medications.

R3’s Physician’s Report was incomplete. The Medication Management section of R3’s Physician’s Report did not have a “Yes” or “No” check on the question of whether R3 is able to administer own PRN medications.

Based on records review, interviews, and observations there is preponderance of evidence to prove the alleged violation did occur, therefore the allegation is substantiated.

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

This report was reviewed with Administrator Candie Ortiz and a copy of the report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 26-AS-20231103161848
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: 02/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/17/2024
Section Cited
CCR
87465(a)(4)
1
2
3
4
5
6
7
(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
1
2
3
4
5
6
7
Licensee agrees to submit a Plan of Correction by POC date to ensure that all residents have correct amounts of medication at all times and staff are trained to properly distribute and account for medications. Licensee shall submit staff training records once trainings are completed.
8
9
10
11
12
13
14
 (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: 3 out of 4 residents did not have the correct amount of medications during medication review, which poses an immediate safety risk to residents in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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 YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 26-AS-20231103161848
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: 02/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/23/2024
Section Cited
CCR
87465(d)(3)
1
2
3
4
5
6
7
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the
1
2
3
4
5
6
7
LIcensee agrees to submit a Proof of Correction by POC date with copies of PRN logs for all residents who require PRN logs and copies of staff in-service trainings to train staff on how to use PRN medication logs.
8
9
10
11
12
13
14
resident with self-administration provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record. This requirement was not met as evidenced by: 1 out of 4 residents who required a PRN medication log did not have a PRN medication log, which poses a potential safety risk to residents in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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 YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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
11/03/2023 and conducted by Evaluator David Marrufo
COMPLAINT CONTROL NUMBER: 26-AS-20231103161848

FACILITY NAME:ROSE GARDEN RCHFACILITY NUMBER:
445294201
ADMINISTRATOR:ROGERS, CANDIEFACILITY TYPE:
740
ADDRESS:310 HATHAWAY AVENUETELEPHONE:
(831) 722-6346
CITY:WATSONVILLESTATE: CAZIP CODE:
95076
CAPACITY:6CENSUS: 4DATE:
02/16/2024
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Candie OrtizTIME COMPLETED:
05:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff handled residents in a rough manner.
Staff forced resident to sit.
Staff forced residents to eat.
Staff left residents in soiled diapers for period of time.
Staff does not keep facility free from odor.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
4 out of 4 interviewed residents stated to have not observed staff handle residents in a rough manner. 3 out of 3 interviewed family members of residents stated to have not observed staff handle residents in a rough manner. 1 out of 2 interviewed co-licensees stated that staff do not handle residents in a rough manner.

1 out of 4 interviewed residents stated to have observed staff forcing residents to sit. 3 out of 4 interviewed residents stated to have not observed staff forcing residents to sit. 3 out of 3 interviewed family members of residents stated to have not observed staff forcing resident to sit. 1 out of 2 co-licensees stated that staff do not force residents to sit.

See LIC9099-C for more information. Page 1 of 2.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 26-AS-20231103161848
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: 02/16/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
4 out of 4 interviewed residents stated to have not observed staff force residents to eat. 3 out of 3 interviewed family members of residents stated staff do not force residents to eat. 1 out of 2 co-licensees stated staff do not force residents to eat.

4 out of 4 interviewed residents stated to have not observed staff leave residents in soiled diapers for an extended period of time. 1 out of 3 interviewed family members of residents stated to have observed staff leaving residents in soiled diapers for an extended period of time. 2 out of 3 interviewed family members of residents stated to have not observed staff leave residents in soiled diapers for an extended period of time. 1 out of 2 co-licensees stated that staff do not leave residents in soiled diapers for an extended period of time.

4 out of 4 interviewed residents stated to have not observed the staff not keeping the facility free from odor. 1 out of 3 interviewed family members of residents stated to have observed the staff not keeping the facility free from odor. 2 out of 3 interviewed family members of residents stated to have not observed the staff not keep the facility free from odor.

Based on information from interviews conducted with staff, residents, and family members of residents, although the allegations listed above may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are unsubstantiated.

No Deficiencies cited under California Code of Regulations Title 22

This report was reviewed with Administrator Candie Ortiz and a copy of this report was provided.

Page 2 of 2.

END REPORT
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6