445294201-10-23-2023-26-AS-JJIN-CYW3P8-20231226172507

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 445294201
Report Date: 10/23/2023
Date Signed: 10/23/2023 04:53:46 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
10/03/2023 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20231003163709

FACILITY NAME:	ROSE GARDEN RCH		FACILITY NUMBER:	445294201
ADMINISTRATOR:	ORTIZ, CANDIE		FACILITY TYPE:	740
ADDRESS:	310 HATHAWAY AVENUE		TELEPHONE:	(831) 722-6346
CITY:	WATSONVILLE	STATE: CA	ZIP CODE:	95076
CAPACITY:	6	CENSUS: 5	DATE:	10/23/2023
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Librada (Lee) Ortiz		TIME COMPLETED:	05:15 PM

ALLEGATION(S):

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Staff is not physically and mentally capable of caring for residents in the facility

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Licensee Librada (Lee) Ortiz. On 10/03/2023, the Department received a complaint with the above allegation. LPA Marrufo conducted an initial complaint investigation visit on 10/11/2023.

A witness reported to the Department that on 10/02/2023, the witness arrived at the facility around 12:30 PM and observed one staff, S1, with three other clients. The witness identified S1 as the developmentally disabled adult child of Licensee Candi Ortiz. The witness stated to have asked S1 how many residents were in the facility sunroom and S1 stated that there was 1, but the witness observed there to be 2 residents in the sunroom.

See LIC9099-C for more information. Page 1 of 2.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 26-AS-20231003163709

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: 10/23/2023

NARRATIVE

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During interview on 10/04/2023, Licensee Candi Ortiz stated that S1 is developmentally disabled and cannot be relied upon to speak the truth. She stated she has Power of Attorney over S1. Licensee Candi Ortiz stated that S1 does not provide care for residents and only assists with chores around the house.

Another witness reported to the Department during an interview on 04/21/2023 to have visited the facility and been let in by S1 while there were not staff in the facility. The witness stated to have been at the facility for about 20 minutes until Licensee Candi Ortiz arrived.

During interview on 10/11/2023, resident R1 stated that S1 assists R1 with getting out of bed in the mornings. R1 stated S1 grabs R1’s hands and lifts R1 out of bed.

LPA Marrufo conducted telephone interviews on 10/23/2023 with two resident responsible parties. One of the responsible parties stated to have observed S1 present at the facility with no other staff visibly present. The other responsible party stated to have observed S1 and another volunteer staff, S2, together at the facility with no other facility staff present. Both responsible parties described S2 as having developmental disabilities and not being capable of providing care to residents. 1 out of 2 responsible parties stated that S1 hands things to residents, opens doors for residents, and brings in wheelchairs to residents.

Based on interviews, there is preponderance of evidence to prove the alleged violation did occur. Therefore, the allegation is substantiated.

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

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

This report was reviewed with Licensee Librada (Lee) Ortiz and a copy of this report and appeal rights were provided.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20231003163709

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: 10/23/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/24/2023 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	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	1 2 3 4 5 6 7	Licensee agrees to submit a Plan of Correction by POC date to ensure that the facility staff are sufficient in numbers and competent to provide the services necessary to meet resident needs.
	8 9 10 11 12 13 14	shall be employed 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 the facility residents were receiving care and supervision personnel who were sufficient in numbers and competent to provide the services necessary to meet resident needs by having volunteers with developmental disabilities alone with residents at the facility, which poses an immediate safety risk to residents in care. An immediate civil penalty of $1000 is being assessed for a repeat violation	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 Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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