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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315920256
Report Date: 04/17/2026
Date Signed: 04/17/2026 11:32:29 AM

Document Has Been Signed on 04/17/2026 11:32 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME:ROSE GARDEN HOME CARE INCFACILITY NUMBER:
315920256
ADMINISTRATOR/
DIRECTOR:		BOT, ALEXFACILITY TYPE:
740
ADDRESS:2145 CUMBERLAND LOOPTELEPHONE:
(916) 308-6650
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY: 6CENSUS: 3DATE:
04/17/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Alex Bot, AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct an annual inspection. LPA met with Administrator Alex Bot during today's inspection. Currently there are 3 resides present in the facility and 2 residents are receiving hospice services.

LPA toured facility with administrator to ensure health and safety of residents in care. LPA toured 5 resident rooms, 2 bathrooms, kitchen, common living spaces, backyard and the garage area. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA toured the backyard and all exits are accessible and unlocked. There is a locked storage for medications and toxins. Food supply is adequate for 2-day perishable and 7-day nonperishable. LPA observed an adequate amount of linens and found the first aid kit to be complete.

LPA reviewed 2 of 3 resident files and 2 staff files. LPA reviewed medications of one residents comparing with Centrally Stored Medication Record and physician orders. A review of staff records indicates that all facility staff has received criminal record clearances and/or are associated to this facility. Staff records reviewed indicated current first aid certificates and training completed.

Deficiencies are cited during today's inspection. Deficiencies cited on the 809-D page.

Exit interview conducted and appeal rights given.
NAME OF LICENSING PROGRAM MANAGER: Troy Ordonez
NAME OF LICENSING PROGRAM ANALYST: Bethany Mirlohi
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/17/2026
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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Document Has Been Signed on 04/17/2026 11:32 AM - It Cannot Be Edited


Created By: Bethany Mirlohi On 04/17/2026 at 11:02 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: ROSE GARDEN HOME CARE INC
FACILITY NUMBER: 315920256

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(a)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above due to emergency disaster plan being incomplete which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/08/2026
Plan of Correction
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Administrator to complete LIC610E form and send a copy into LPA. Completed LIC610E to be sent into LPA by 5/8/26.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above due to no documented fire drills being completed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/08/2026
Plan of Correction
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Administrator to complete a disaster drill and document required information. Documentation of disaster drill to be sent into LPA by 5/8/26.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Troy Ordonez
NAME OF LICENSING PROGRAM MANAGER:
Bethany Mirlohi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/17/2026 11:32 AM - It Cannot Be Edited


Created By: Bethany Mirlohi On 04/17/2026 at 11:15 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: ROSE GARDEN HOME CARE INC
FACILITY NUMBER: 315920256

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(a)
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 3 files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/08/2026
Plan of Correction
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Administrator to complete updated needs and service plan for the 2 residents and send a copy into LPA by 5/8/26.
Type B
Section Cited
CCR
87208(a)(12)
(a) The licensee shall have and maintain a current, written definitive plan of operation for the facility. The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so pursuant to Health and Safety Code section 1569.49. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: (12) The Infection Control Plan pursuant to Section 87470.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having an infection control plan which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/08/2026
Plan of Correction
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Administrator to complete an infection control plan and send LPA a copy by 5/8/26.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Troy Ordonez
NAME OF LICENSING PROGRAM MANAGER:
Bethany Mirlohi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2026


LIC809 (FAS) - (06/04)
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