445294201-3-13-2024-26-AS-JJIN-D562TS-20240510174108

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 445294201
Report Date: 03/13/2024
Date Signed: 03/13/2024 04:40:48 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
12/28/2023 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20231228100948

FACILITY NAME:	ROSE GARDEN RCH		FACILITY NUMBER:	445294201
ADMINISTRATOR:	ROGERS, CANDIE		FACILITY TYPE:	740
ADDRESS:	310 HATHAWAY AVENUE		TELEPHONE:	(831) 722-6346
CITY:	WATSONVILLE	STATE: CA	ZIP CODE:	95076
CAPACITY:	6	CENSUS: 5	DATE:	03/13/2024
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Lee Najera		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Licensees failed to arrange for medical care for resident's injury that resulted from a fall

INVESTIGATION FINDINGS:

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

On 12/28/2023, the Department received a complaint with the above allegation. On 01/02/2024, the Department conducted an initial complaint investigation visit. The Investigative Bureau conducted additional investigation. The Department obtained a digital photograph of resident R1’s face visibly showing a yellowed bruise across R1’s forehead and right side of R1’s face and a swollen welt in the middle of R1’s forehead. The digital photograph’s metadata indicates the photograph was taken on 09/16/2023.

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: 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.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 26-AS-20231228100948

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: 03/13/2024

NARRATIVE

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During interview on 01/30/2024, Administrator Candie Ortiz stated that she believed resident R1 fell off R1’s bed and hit R1’s head on a nightstand, causing the facial injury. Administrator Ortiz stated that staff S1 and R1’s Family Member F1 witnessed the injury incident. S1 denied being present when R1 fell and stated to not know how R1 became bruised. F1 denied any knowledge of R1 suffering any falls while in care at the facility and stated to have not seen R1 with any bruising or signs of neglect.

Administrator Ortiz stated that R1 began showing facial bruising two days after the fall incident. Administrator Ortiz stated to have not sought medical attention for R1 as Administrator Ortiz believed that it was F1’s responsibility to seek medical attention for R1 and not hers. Administrator Ortiz stated to have applied ice to R1’s face to alleviate the bruising.

A deficiency was cited as per California Code of Regulations Title 22. See LIC9099-D for more information.

An immediate civil penalty of $500 is being assessed today for serious bodily injury. Additional civil penalties are pending review.

This report was reviewed with Lee Najera 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: 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

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20231228100948

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: 03/13/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 03/14/2024 Section Cited CCR 87465(a)(1)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (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,	1 2 3 4 5 6 7	Licensee agrees to submit a Plan of Correction by POC date stating how the licensee will conduct in-service training with staff to ensure that staff will arrange for medical or dental care appropriate to the conditions and needs of residents.
	8 9 10 11 12 13 14	by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by: Licensee did not ensure that staff arranged or assisted in arranging appropriate medical care after R1 suffered a fall-related injury to the head and face, which poses an immediate safety risk to residents in care. *An immediate civil penalty of $500 is being assessed*	8 9 10 11 12 13 14	Once in-service trainings are completed, Licensee shall submit copies of training records to CCL.
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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	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 3 of 3