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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803886
Report Date: 04/16/2025
Date Signed: 04/16/2025 04:29:29 PM

Document Has Been Signed on 04/16/2025 04:29 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:H & M'S THE ROSE GARDENFACILITY NUMBER:
496803886
ADMINISTRATOR/
DIRECTOR:		GARCIA, MAGGIEFACILITY TYPE:
740
ADDRESS:2370 MELBROOK WAYTELEPHONE:
(707) 546-2429
CITY:SANTA ROSASTATE: CAZIP CODE:
95405
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
04/16/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:07 AM
MET WITH:Maggie Garcia, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:43 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by caregiver. Administrators Maggie and Heherson Garcia arrived later. Maggie Garcia Administrator Certificate 7008481740 expires 5/5/2025.

At approximately 9:30am LPA and Admin toured the building and grounds. Facility currently has six [6] residents in care, none of which are on hospice. LPA observed a noticeable order of incontinence upon entering facility (deficiency cited, see 809D). LPA observed items in bathroom such as storage rack and paper towel holder in bathroom to be dirty and dusty. The facility was found to be at a comfortable temperature. LPA observed camera to be present in the kitchen and in the common area living room. LPA asked to see notification and consent form signed by the residents' or residents' responsible parties for the cameras. Admin provided LPA a form with signatures, but none of the signatures matched the signatures of the residents or residents' responsible parties and the dates of the signatures is before many of the residents moved into the facility. LPA advised Admin to disclose and obtain the consent of residents and/or residents' responsible parties when utilizing video surveillance within the facility.

LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Facility had fresh fruit but no fresh vegetables. Admin claims that today she was going to replenish the facility's supply of fresh vegetables, so Admin immediately went to store and purchased some fresh lettuce and vegetables. LPA observed opened bag of sugar and coffee in pantry without any seal or label. LPA advised to keep open items properly sealed after opening. Kitchen cabinet containing cleaning supplies was locked. Kitchen drawer with sharp knives locked. LPA observed a pair of scissors in unlocked kitchen drawer. LPA advised to keep objects that could present as a hazard to residents in locked drawer.

Continued on 809...
Victoria BertozziTELEPHONE: (707) 588-5059
Christi CoppoTELEPHONE: (707) 588-5054
DATE: 04/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/16/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: H & M'S THE ROSE GARDEN
FACILITY NUMBER: 496803886
VISIT DATE: 04/16/2025
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Continued from 809...

All bedrooms were equipped with lighting, night stand, and chest of drawers. R1 and R2 do not have a comfortable mattress with good springs (deficiency cited, see 809D). R3 did not have a pillow. Admin claims R3 does not want a pillow. LPA advised to keep one out and available in case R3 does want a pillow. Extra hygiene products and linens were available. Resident bathroom had required bath mat and grab bar. Water temperature in sink accessible to residents in care measured at 110.4 and degrees F which is within the allowable range of 105 to 120 degrees F.

Fire extinguishers were last inspected 1/13/25. Sprinklers and Smoke/Carbon Monoxide detectors located throughout the facility are hard wired and serviced by vendor. Last date of service January 2025. Facility’s last quarterly disaster drills were conducted March 2025. Facility has a backup generator for use during a power outage. LPA and Admin observed two boards on side of wrap around deck to bow when pressure is applied. On the same two boards there are nails that stick up, as they are not flush with the board, presenting a hazard to residents. Admin immediately hammered down nails and will replace boards or make them secure within one week.

At approximately 11:45am LPA conducted a review of six [6] resident records. No deficiencies cited. LPA reviewed with Admins discrepancies found on residents' physician assessments. Admins will follow up and get corrections/clarifications to diagnoses and ambulatory status listed on residents' respective physician assessments. LPA observed R4's right eye to be very red and appears to be inflamed. Admin advised LPA that R4 just had a doctor visit on 2/28/25. However, eye issue was not addressed at visit per LPA review of discharge papers. Admin will have R4's eye looked at by their doctor as soon as possible.

At approximately 1:00pm LPA conducted review of five [5] staff records. LPA reviewed training documentation forms created by the facility. Training records present do not list hours completed. LPA advised Admins that their documentation of training must include the hour duration of the training completed and the course topics covered. Currently, there is no hour duration listed except for shadowing hours or RCFE Initial training hours. However, staff initial training hours certificate does not list topics covered. LPA


Continued on 809C(2)...
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2025
LIC809 (FAS) - (06/04)
Page: 3 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: H & M'S THE ROSE GARDEN
FACILITY NUMBER: 496803886
VISIT DATE: 04/16/2025
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Continued from 809C...

reviewed training materials and observed three [3] items present for training: Paper materials and CDs dated 2008 from Community Care Options, videos from Community Care Options dated 2011, and a California Dementia Care Compliance book from Allen Flores dated 2025. LPA advised that training materials should be current, within the decade, and cover all the required subject topics per regulation, not just dementia but also hospice care, postural supports, and restricted conditions among other topics. LPA went over Health and Safety Code with Admins outlining the topics required and hours required. Additionally, LPA and Admins discussed either obtaining current materials and submitting them to CCL for approval or using an approved vendor. Admins decided to use the approved vendor of Community Care Options going forward.

At approximately 2:45pm LPA and Admin conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet. LPA found discrepancies with medication for R2 and R5. Pertaining to R5:Prescription Eliquis 5mg filled 3/19/25 count was off. Quantity of 60 bottle started on 3/19/25 and R2 is supposed to receive 2 tablets per day, but one pill left in the bottle. Prescription Levetiracetam 500mg count was off. Quantity of 120 bottle started 3/6/25 and R2 is supposed to receive 1 tab per day but 37 pills remain. Pertaining to R2: R2 had hydrocortisone prescribed on 3/6/25 but LPA did not observe the cream in R2's medication bin. Medication not listed as PRN on doctor's orders however, per Admin, medication was never filled and never added to Centrally Stored Medication Log (deficiency cited. see 809D). LPA discussed and offered Technical Support Program for medication management help from CCL. Admins declined offer and will reconcile medication records and medications on their own for now.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with Administrators and a copy of this report was given.

SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/16/2025 04:29 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: H & M'S THE ROSE GARDEN
FACILITY NUMBER: 496803886

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and Admin observation and record review, the licensee did not comply with the section cited above in that R5 prescription Eliquis 5mg filled 3/19/25 count was off. Quantity of 60 bottle started on 3/19/25 and R5 is supposed to receive 2 tablets per day, but one pill left in the bottle. R5's prescription Levetiracetam 500mg count was off. Quantity of 120 bottle started 3/6/25 and R5 is supposed to receive 1 tab per day but 37 pills remain. R2 had hydrocortisone prescribed on 3/6/25 but LPA did not observe the cream in R2's medication bin. Medication not listed as PRN on doctor's orders however, per Admin, medication was never filled and never added to Centrally Stored Medication Log, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2025
Plan of Correction
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Facility to submit plan to CCL to train all staff that assist residents with medication on proper medication management and filling of prescriptions by plan of correction due date. Training to be completed no later than 4/23/25. Proof of training due by no later than 4/23/25.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Victoria BertozziTELEPHONE: (707) 588-5059
Christi CoppoTELEPHONE: (707) 588-5054

DATE: 04/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2025

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/16/2025 04:29 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: H & M'S THE ROSE GARDEN
FACILITY NUMBER: 496803886

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
CCR
87307(a)(3)(A)
Personal Accommodations and Services
(A) A bed for each resident, except that married couples may be provided with one appropriate sized bed. Each bed shall be equipped with good springs, a clean and comfortable mattress, available pillow(s) and lightweight warm bedding. Fillings and covers for mattresses and pillows shall be flame retardant. Rubber sheeting shall be provided when necessary.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and Admin observation, the licensee did not comply with the section cited above in that R1 and R2 do not have a mattress with good springs or that is comfortable. R3 did not have a pillow, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/23/2025
Plan of Correction
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Facility has purchased 2 foam mattresses specifically for reducing pressure and have made available a pillow for R3. Facility to submit receipts for beds by plan of correction due date along with pictures of newly added mattresses.
Type B
Section Cited
CCR
87625(b)(3)
Managed Incontinence
(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and Admin observation, the licensee did not comply with the section cited above in that LPA observed a noticeable order of incontinence upon entering facility, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/23/2025
Plan of Correction
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Facility to submit LIC9098 self-certifying that facility will remain free from incontinence odors at all times by plan of correction due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Victoria BertozziTELEPHONE: (707) 588-5059
Christi CoppoTELEPHONE: (707) 588-5054

DATE: 04/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2025

LIC809 (FAS) - (06/04)
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