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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445294201
Report Date: 11/08/2023
Date Signed: 11/08/2023 03:34:49 PM


Document Has Been Signed on 11/08/2023 03:34 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: 4DATE:
11/08/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Librada "Lee" NajeraTIME COMPLETED:
03:45 PM
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
Licensing Program Analyst (LPA) David Marrufo conducted a Case Management visit and met with Co-Licensee Librada "Lee" Najera. LPA Marrufo conducted a Case Management visit to cite the facility for a deficiency observed during a complaint investigation visit.

LPA Marrufo requested resident records, including Medication Administration Records (MAR) and Centrally Stored Medication Logs (CSML), but Co-Licensee/Administrator Candi Rogers stated over telephone that the resident records were locked in a cabinet and she was not present at the facility to be able to open the cabinet. Administrator Rogers also stated that the MAR and CSML records are kept on a computer software, and those records are not currently accessible to staff to provide to LPA Marrufo. Co-Licensee Najera provided LPA Marrufo with two partial resident records during visit.

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

This report was reviewed with Co-Licensee Najera 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: 11/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2023
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 11/08/2023 03:34 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: 11/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/15/2023
Section Cited
CCR
87506(d)

1
2
3
4
5
6
7
87506(d) Resident Records (d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. This requirement was not met as evidenced by: Licensee did not ensure that all resident records, including Medication Administration
1
2
3
4
5
6
7
Licensee agrees to make all resident records available to the licensing agency to inspect, audit, and copy upon demand during normal business hours by POC date and submit a statement of completion to CCL by POC once the records have been made available.
8
9
10
11
12
13
14
Records and Centrally Stored Medication Records, were available to the licensing agency on demand during normal business hours when LPA Marrufo visited the facility and requested the records, 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: 11/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2