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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445294201
Report Date: 11/14/2023
Date Signed: 11/14/2023 01:42:22 PM


Document Has Been Signed on 11/14/2023 01:42 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: DATE:
11/14/2023
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Candie RogersTIME COMPLETED:
01:45 PM
NARRATIVE
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On 10/4/23 San Bruno Regional Office - San Jose Unit conducted a non-compliance conference meeting with Licensees Candi Rogers and Librada Najera.

Present in the meeting were Regional Manage Vivien Helbling, Licensing Program Managers April Cowan and Jackie Jin, and Licensing Program Analyst David Marrufo and Maria Partoza.
 
During the non-compliance meeting, the following violations were discussed: 87468.1(a)(3) Personal Rights of Residents in All Facilities, 87468.1(a)(1) Personal Rights of Residents in All Facilities, 87465(g) Incidental Medical and Dental Care, 87405(b) Administrator Qualifications, 87705(c)(4)(A) Care of Persons with Dementia, 87411(a) Personnel Requirements – General, 87207 False Claims, 87705(j) Care of Persons with Dementia, 87411(j) Personnel Requirements - General, 87355(e)(1): Criminal Record Clearance.

During this meeting, it was discussed that Licensee will receive more frequent monitoring inspection visits to ensure compliance with this compliance plan and Title 22 Regulations for 2 years. Licensee was provided the link below for resources and guidance to improve facility operations: 
https://www.cdss.ca.gov/inforesources/community-care/resource-guide-for-providers.

During this meeting, deficiencies were issued as per California Code of Regulations Title 22 for the following deficiencies found during a complaint investigation: R1's Physician's Report was completed on 06/23/2021 and did not receive an annual update. R1's Physician's Report states R1 had dementia, had wandering behavior, and was not able to leave the facility unassisted. R1's Reappraisal was completed on 07/30/2021, did not receive an annual update, and does not include a plan for addressing R1's wandering behavior. On 11/14/2022, R1 wandered from the facility and was found found deceased at 6:10 AM.
See LIC809-D for more information. Page 1 of 2.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2023
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 3


Document Has Been Signed on 11/14/2023 01:42 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: 11/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/21/2023
Section Cited
CCR
87705(c)(5)

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87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall
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Licensee ensures that all medical assessments and reappraisals of residents with dementia are done at least annually and their reappraisals include care for any wandering and/or sundowning behaviors.
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include a reassessment of the resident’s dementia care needs. This requirement was not met as evidenced by: Licensee did not ensure that R1's Medical Assessment and Reappraisal had annual updates and did not ensure R1's Reappraisal included care for R1's wandering behaviors, which poses an immediate safety risk to residents in care.
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Licensee shall submit a statement of correction along with copies of any updated medical assessments and Appraisal/Needs and Services Plans by POC date.

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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: 11/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3


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
VISIT DATE: 11/14/2023
NARRATIVE
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The CCLD requests that the Licensee submit an updated copy of the LIC500 Personnel Report by 12/06/2023.

This report was reviewed with Licensees Candi Rogers and Librada 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: 11/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3