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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445294201
Report Date: 10/23/2023
Date Signed: 10/23/2023 04:40:04 PM


Document Has Been Signed on 10/23/2023 04:40 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:
10/23/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Librada OrtizTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Licensee Librada Ortiz.

The purpose of the Case Management visit was to cite the facility for deficiencies related to a complaint investigation.

Deficiencies were cited as per California Code of Regulations Title 22. See LIC809-D for more information.

An immediate civil penalty of $250 is being issued today for a repeat violation.

This report was reviewed with Licensee Librada Ortiz 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: 10/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2023
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 11/14/2023 01:44 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 11/14/2023 08:47 AM

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: 10/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/24/2023
Section Cited
CCR
87411(j)

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(j) Volunteers may be utilized but may not be included in the facility staffing plan. Volunteers shall be supervised. This requirement was not met as evidenced by: Licensee did not ensure that
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Licensee agrees to submit a Plan of Correction by POC date to ensure that all volunteers are supervised by staff while at the facility.
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volunteers were supervised by staff at the facility, which poses an immediate safety risk to residents in care.
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Type A
10/24/2023
Section Cited
CCR87207

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No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement was not met as evidenced by:
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Licensee shall submit a Plan by POC date about how the licensee will ensure that the Licensee will not make false statements about the facility, including to Department investigators.
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 Licensee did not ensure that the licensee did not make false claims about a volunteer providing care to the residents at the facility, which poses an immediate safety risk to residents in care. ** An immediate civil penalty is being assessed for $250 for a repeat violation. ** **This page was amended to include the Licensee's signature. **
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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: 10/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2