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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 445294201
Report Date: 10/02/2023
Date Signed: 10/02/2023 05:04:06 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
11/15/2022 and conducted by Evaluator David Marrufo
COMPLAINT CONTROL NUMBER: 26-AS-20221115130515
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:
10/02/2023
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Basillia SaldivarTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Facility failed to contact 911 after staff found resident to be missing
Staff did not provide adequate supervision resulting in resident wandering from facility and being found deceased
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Basillia Saldivar.

On 11/15/2022, the Department received a complaint with the above allegations. The Department conducted an initial complaint investigation visit on 11/15/2022.

On 5/11/2023, the Department conducted interviews with facility staff. Staff S1 stated to have been the only staff on the night of 11/13/2022. At 1:00 AM on 11/14/2022, S1 observed that resident R1 was missing from the facility.


See LIC9099-C for more information. Page 1 of 2.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2023
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 5
Control Number 26-AS-20221115130515
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: 10/02/2023
NARRATIVE
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When S1 observed that R1 was missing, S1 called the Santa Cruz Sherriff’s substation. Records from the Santa Cruz County Sherriff’s Office indicate there were telephone calls made from the facility telephone number to the Sherriff’s substation office at 6:10 AM and 6:11 AM.

Interviews with staff and residents showed that staff were unaware that R1 was regularly prone to wander at night. Staff failed to provide adequate supervision regarding R1’s known sundowning. Staff failed to ensure the security of facility doors, which allowed R1 to leave through two doors and the back gate. Staff failed to provide routine supervision between the hours of 1:00 AM and 3:00 AM. S1 failed to contact the Santa Cruz County Sherriff’s office upon discovering that R1 was missing and did not call law enforcement until 6:10 AM.

Based on records review and interviews, there is preponderance of evidence to prove the alleged violations did occur. Therefore, the allegations are substantiated.

See 9099-D for deficiencies cited per the California Code of Regulations, Title 22.

Two immediate civil penalties of $500 are being assessed today, coming to a total of $1000. Additional civil penalties for violations resulting in death are pending review.

This report was reviewed with Basillia Saldivar and a copy of this report and appeal rights were provided.



Page 2 of 2.

END REPORT
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
11/15/2022 and conducted by Evaluator David Marrufo
COMPLAINT CONTROL NUMBER: 26-AS-20221115130515

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:
10/02/2023
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Basillia SaldivarTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Staff did not seek medical attention in a timely manner
INVESTIGATION FINDINGS:
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During interview on 05/11/2023, staff S1 stated that on 11/13/2022, S1 had gotten up at 11:00 PM with a flashlight and checked on the residents. S1 physically saw resident R1 in bed. At 1:00 AM on 11/14/2022, S1 heard a noise and checked R1’s room again and observed R1 was no longer in R1’s bedroom. At 6:00 AM on 11/14/2022, Staff S2 and Licensee’s Family Member F1 went to look for R1 around the neighborhood and found R1 lying deceased in a driveway.

This agency has investigated the complaint allegation listed. Based on interviews and review of records, the CCLD has found that the complaint allegation is unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

This report was reviewed with Basillia Saldivar and a copy of the report was provided.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 26-AS-20221115130515
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: 10/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/03/2023
Section Cited
CCR
87465(g)
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87465(g) Incidental Medical and Dental Care: (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening
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Licensee agrees to submit a Plan of Correction to CCL by POC date stating how staff will receive in-service training on calling 911 immediately when a resident has an injury or in any other circumstance
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medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement was not met as evidenced by: Licensee did not immediately call 911 when resident R1 was observed at 1:00 AM to be missing from the facility until 6:10 AM. An immediate civil penalty of $500 is being assessed and an additional civil penalty for violations resulting in death is pending review, which poses an immediate safety risk to residents in care.
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that has resulted in an immediate threat to a resident’s health. Once training is completed, Licensee shall submit training records to CCL.
Type A
10/03/2023
Section Cited
CCR
87405(b)
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87405(b) Administrator Qualifications: (b) The administrator of a facility or facilities shall have the responsibility and authority to carry out the policies of the licensee. This requirement was not met as
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Licensee agrees to submit a Plan of Correction to CCL by POC date stating how Licensee shall receive training on how to properly direct staff during emergency situations.
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evidenced by: Licensee did not instruct facility staff to immediately call 911 when resident R1 was missing from the facility, which poses an immediate safety risk to residents in care.
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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: 10/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 26-AS-20221115130515
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: 10/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/03/2023
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, including preventing residents from wandering.
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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 on the night that R1 wandered from the facility there was a sufficient number of staff and staff who were competent to provide the services necessary to meet resident needs, including preventing R1 from wandering from the facility, which poses an immediate safety risk to residents in care. An immediate civil penalty of $500 is being assessed and an additional civil penalty for violations resulting in death is pending review, which poses an immediate safety risk to residents in care.
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Type A
11/15/2023
Section Cited
CCR
87705(c)(4)
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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:(4) here is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and
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Licensee agrees to submit a Plan of Correction by POC date to CCL stating how the Licensee shall ensure that there will be an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and
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health care needs as identified in his/her current appraisal. This requirement was not met as evidenced by: Licensee did not ensure that was an adequate number of direct care staff to support each resident's physical, social, emotional, safety and health care needs as identified in his/her current appraisal, including R1's dementia diagnosis and wandering behavior, which poses an immediate safety risk to residents in care. **This report was amended on 11/14/2023 to add this citation**
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health care needs as identified in his/her current appraisal, including resident's dementia care needs.
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: 10/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5