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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445294201
Report Date: 10/11/2023
Date Signed: 10/11/2023 04:57:25 PM


Document Has Been Signed on 10/11/2023 04:57 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:ORTIZ, CANDIEFACILITY TYPE:
740
ADDRESS:310 HATHAWAY AVENUETELEPHONE:
(831) 722-6346
CITY:WATSONVILLESTATE: CAZIP CODE:
95076
CAPACITY:6CENSUS: 5DATE:
10/11/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Candi RogersTIME COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) David Marrufo conducted a case management visit and met with Candi Rogers. LPA Marrufo was at the facility to investigate complaints.

During visit, LPA Marrufo observed Licensee Librada (Lee) Najera walk out of the facility at 1:13 PM to assist resident R1, who was being dropped off by van at the sidewalk in front of the facility. While Licensee Najera was outside of the facility, there were two residents in the facility. Resident R2 was in the living room and R3 was in the sun room. LPA Marrufo observed Licensee Najera return to the facility with R1 at 1:17 PM. LPA Marrufo interviewed Licensee Najera, who stated there were no other staff working at the facility at the time.

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

An immediate civil penalty for repeat violations of $1000 is being assessed today.

This report was reviewed with Candi Rogers and a copy of the 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: 10/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 10/11/2023 04:57 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: 10/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/12/2023
Section Cited
CCR
87411(a)

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87411(a) Personnel Requirements – General: (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed
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Licensee agrees to submit a Plan of Correction by POC date to CCL stating how Licensee shall ensure that staff at all times be in sufficient numbers and competent to provide the services necessary to meet resident needs.
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 to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement was not met as evidenced by: Licensee did not ensure that a staff was supervising two residents inside of the facility when Licensee exited the facility to assist a resident into the facility, which poses an immediate safety risk to residents in care. An immediate civil penalty for repeat violations of $1000 is being assessed today.
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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: 10/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2