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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405802285
Report Date: 05/12/2022
Date Signed: 05/12/2022 06:00:08 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/10/2022 and conducted by Evaluator Darlene Chavez
COMPLAINT CONTROL NUMBER: 29-AS-20220510165033
FACILITY NAME:ROSE GARDENFACILITY NUMBER:
405802285
ADMINISTRATOR:DIANA BARNHILLFACILITY TYPE:
740
ADDRESS:6100 LOS GATOS ROADTELEPHONE:
(805) 466-2506
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY:6CENSUS: 3DATE:
05/12/2022
UNANNOUNCEDTIME BEGAN:
05:10 PM
MET WITH:Diana Barnhill, Licensee/AdministratorTIME COMPLETED:
06:10 PM
ALLEGATION(S):
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Staff are not wearing PPE
INVESTIGATION FINDINGS:
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On 5/12/2022 at 5:10 pm, Licensing Program Analyst (LPA) Chavez conducted a 10-day unannounced complaint investigation at the facility listed above. LPA met with Diana Barnhill, Licensee/Administrator and explained the purpose of the visit.

Regarding the allegation “Staff are not wearing PPE,” the complainant’s concern was that a caregiver was not wearing a face covering while opening the front door to visitors. To investigate the allegation, LPA interviewed a credible witness, the licensee/administrator, toured the facility, and obtained documentation.

On 5/05/2022 at 12:15 pm, credible Witnesses #1 and #2 (W1 and W2) observed Staff #1 (S1) greeting visitors at the front door without wearing a face covering. S1 stated that they had “removed the mask because I had to cough.”

Continued on 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022
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 29-AS-20220510165033
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ROSE GARDEN
FACILITY NUMBER: 405802285
VISIT DATE: 05/12/2022
NARRATIVE
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On 5/12/2022 at 5:10 pm, LPA observed Staff #2 (S2) wearing a mask below S2’s nose when answering the front door. LPA asked staff to wear the mask fully covering the nose and mouth, and staff complied.

Based on observations, the allegation “Staff are not wearing PPE,” is deemed Substantiated at this time. The facility did not protect the personal rights of residents in care to be able to receive safe and healthful accommodations in that facility staff failed to wear face coverings properly while providing care and supervision to residents in care and while greeting visitors. This is a violation of official government orders requiring the wearing of face coverings while working under specified conditions.

Pursuant to Title 22, California Code of Regulations, the deficiency will be cited on 9099-D.

Exit interview conducted, deficiency cited, a copy of this report and appeal rights emailed to Licensee.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20220510165033
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ROSE GARDEN
FACILITY NUMBER: 405802285
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/13/2022
Section Cited
CCR
87468.1
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87468.1 – Personal Rights. Residents have the right to be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by:
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Licensee has agreed to direct staff to change their masks two to three times in one shift. Licensee will also hold infectious control training specifically on proper PPE usage. Licensee will provide a copy of the training and staff signatures to CCL by 5/13/22.
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Based on observations, the facility failed to ensure staff were wearing face coverings which poses an immediate health, safety and personal rights 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.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3