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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445294201
Report Date: 03/13/2024
Date Signed: 03/13/2024 04:47:05 PM


Document Has Been Signed on 03/13/2024 04:47 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 RCHFACILITY NUMBER:
445294201
ADMINISTRATOR:ROGERS, CANDIEFACILITY TYPE:
740
ADDRESS:310 HATHAWAY AVENUETELEPHONE:
(831) 722-6346
CITY:WATSONVILLESTATE: CAZIP CODE:
95076
CAPACITY:6CENSUS: 5DATE:
03/13/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Lee NajeraTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Lee Najera. The purpose of the visit was to address deficiencies that were found during a complaint investigation that the Department received on 12/28/2023.

The Department obtained a digital photograph that depicted R1 with bruising across the forehead and right side of the face as well as a swollen welt in the middle of R1’s forehead.

During the investigation, Administrator Candie Ortiz stated that resident R1 fell from R1’s bed and hit R1’s head on a night stand. Administrator Ortiz stated to have applied ice on R1’s face to alleviate the bruising.

Administrator Ortiz did not report R1’s fall to the Department.

A deficiency was cited as per California Code of Regulations Title 22. See LIC809-D for more information.


This report was reviewed with Lee Najera and a copy of this report and appeal rights were provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE: 03/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2024
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 03/13/2024 04:47 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 RCH
FACILITY NUMBER: 445294201

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
03/20/2024
Section Cited
CCR
87211(a)(1)(D)

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Reporting Requirements 87211(a)(D) (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.
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Licensee agrees to submit a Plan of Correction to CCL by POC date to in-service staff on submitting Unusual Incident/Injury reports to CCL if there is any incident which threatens the welfare, safety, or health of a resident and submit copies of the training records to CCL by POC date.
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This requirement was not met as evidenced by: Licensee failed to furnish an Unusual Incident/Injury Report to the Department when resident R1 had a fall-related injury to the head and face, which poses a potential safety risk to residents 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: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE: 03/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2024
LIC809 (FAS) - (06/04)
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