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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405802285
Report Date: 08/16/2023
Date Signed: 08/16/2023 07:22:02 PM

Document Has Been Signed on 08/16/2023 07:22 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
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: 6DATE:
08/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Diana Barnhill, Licensee/AdministratorTIME COMPLETED:
07:30 PM
NARRATIVE
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On 8/16/23 at 10:30 am, Licensing Program Analyst (LPA) Chavez made an unannounced Annual/Required visit to the facility listed above. LPA met with Staff #1 (S1), caregiver, and explained the purpose of the visit. At approximately 11:30 am, Diana Barnhill, Licensee/Administrator, arrived at the facility.

A tour of the physical plant was assessed, and the following was noted: LPA observed the license posted, Complaint Poster, Bill of Rights and Right to Residential Council, non-discrimination statement, and resident rights in the front entry.
Physical plant was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, and doors were checked, all in good condition. The facility maintains a comfortable temperature. The smoke detectors are hard-wired, and carbon monoxide detectors were tested and operational. Fire extinguishers (2) located in the kitchen were inspected on 8/4/23 and are charged in the green. There are no issues with Fire Clearance.
Living room and dining room furniture were checked and in good condition. The common rooms are clean, safe and sanitary.
The courtyards of the facility have outdoor furniture with shaded area for residents. The facility has two wooden gates on each side of the perimeter. The gate on the north side closes only if aggressively pushed and does not automatically close. Technical violation issued. The facility also has two rod iron fences and gates with latches on the outside disabling residents from opening the gates easily. Residents would have to reach over the gate to open. Technical violation issued. Licensee will relocate the latches to inside the gates and will send LPA photos by 8/23/23.
The kitchen is sufficiently stocked with two-day perishable and seven-day non-perishables. Foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers. Refrigerator is kept at 45 F degrees. Technical violation issued. The freezer measured at 0 F degrees. The kitchen has a cabinet under the sink without a lock containing dish soap and powdered bleach. Deficiency cited. Staff immediately moved the items to a locked cabinet. Continued on 809-C.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 8
Document Has Been Signed on 08/16/2023 07:22 PM - It Cannot Be Edited


Created By: Darlene Chavez On 08/16/2023 at 06:29 PM
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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ROSE GARDEN
FACILITY NUMBER: 405802285

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.17(b)(1)(C)
Licensing
(C) Any person who provides client assistance in dressing, grooming, bathing, or personal hygiene. Any nurse assistant or home health aide meeting the requirements of Section 1338.5 or 1736.6, respectively, who is not employed, retained, or contracted by the licensee, and who has been certified or recertified on or after July 1, 1998, shall be deemed to meet the criminal record clearance requirements of this section. A certified nurse assistant and certified home health aide who will be providing client assistance and who falls under this exemption shall provide one copy of their current certification, prior to providing care, to the residential care facility for the elderly. The facility shall maintain the copy of the certification on file as long as the care is being provided by the certified nurse assistant or certified home health aide at the facility. Nothing in this paragraph restricts the right of the department to exclude a certified nurse assistant or certified home health aide from a licensed residential care facility for the elderly pursuant to Section 1569.58.

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 one out of five staff did not have a background clerance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2023
Plan of Correction
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Licensee immediately instructed S1 to leave the facility and return only when a background clearance is obtained. No further action needed.

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:Kelly Burley
LICENSING EVALUATOR NAME:Darlene Chavez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2023


LIC809 (FAS) - (06/04)
Page: 2 of 8
Document Has Been Signed on 08/16/2023 07:22 PM - It Cannot Be Edited


Created By: Darlene Chavez On 08/16/2023 at 06:29 PM
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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ROSE GARDEN
FACILITY NUMBER: 405802285

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interviews, the licensee did not comply with the section cited above in that documentation is not available showing proof of liability insurance which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2023
Plan of Correction
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Licensee will obtain documentation showing proof of liability insurance and send to CCL.
Type B
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that cleaning supplies were in an unlocked kitchen cabinet accessible to residents in care which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2023
Plan of Correction
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Staff immediately removed the items and placed in a locked cabinet. Licensee will conduct training on the regulation cited above and send a copy of the training sign-in sheet to LPA by 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.
SUPERVISOR'S NAME:Kelly Burley
LICENSING EVALUATOR NAME:Darlene Chavez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2023


LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 08/16/2023 07:22 PM - It Cannot Be Edited


Created By: Darlene Chavez On 08/16/2023 at 06:29 PM
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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ROSE GARDEN
FACILITY NUMBER: 405802285

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interviews, the licensee did not comply with the section cited above in S2 had an expired first aid certification which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2023
Plan of Correction
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Licensee will ensure that all staff have first-aid certification completed and sent copy to LPA by the due date.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interviews, the licensee did not comply with the section cited above in five out of five staff did not complete annual required training which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2023
Plan of Correction
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Licensee will ensure all staff complete annual required training and send proof to LPA by 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.
SUPERVISOR'S NAME:Kelly Burley
LICENSING EVALUATOR NAME:Darlene Chavez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2023


LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 08/16/2023 07:22 PM - It Cannot Be Edited


Created By: Darlene Chavez On 08/16/2023 at 06:29 PM
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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ROSE GARDEN
FACILITY NUMBER: 405802285

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 and interviews, the licensee did not comply with the section cited above in quarterly emergency drills were not completed for the past year which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2023
Plan of Correction
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Licensee will write a statement of understanding commiting to conducting and documenting quarterly emergency disaster drills in the future and send the statement to LPA by due date.
Type B
Section Cited
CCR
87705(d)
Care of Persons with Dementia
(d) In addition to requirements specified in Section 87303, Maintenance and Operation, safety modifications shall include, but not be limited to, inaccessibility of ranges, heaters, wood stoves, inserts, and other heating devices to residents with dementia.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that the stove had knobs (6) allowing residents to turn on the stove which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2023
Plan of Correction
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Licensee has committed to installing plastic child-proof covers for stove knobs and will send a photo to LPA by 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.
SUPERVISOR'S NAME:Kelly Burley
LICENSING EVALUATOR NAME:Darlene Chavez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2023


LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 08/16/2023 07:22 PM - It Cannot Be Edited


Created By: Darlene Chavez On 08/16/2023 at 06:29 PM
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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ROSE GARDEN
FACILITY NUMBER: 405802285

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, the licensee did not comply with the section cited above in that knives and scissors were stored in an unlocked kitchen cabinet which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2023
Plan of Correction
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Staff immediately removed the knives/scissors and placed in a locked cabinet. Licensee will place knives/scissors in a locked drawer and send photo to LPA by due date.
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.
SUPERVISOR'S NAME:Kelly Burley
LICENSING EVALUATOR NAME:Darlene Chavez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2023


LIC809 (FAS) - (06/04)
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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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ROSE GARDEN
FACILITY NUMBER: 405802285
VISIT DATE: 08/16/2023
NARRATIVE
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The kitchen's stove has knobs (6) attached and the kitchen is accessible to residents in care. Deficiency cited. Approximately 4 knives and a pair of scissors were observed in an unlocked kitchen cabinet above the oven. The kitchen is accessible to residents in care. Deficiency cited.
Resident rooms are adequately dressed with sheets, pillowcase, mattress pad, and blankets which are in good condition. There is at least one chair, nightstand and sufficient lighting for each resident. There is enough linen available to change regularly.
Storage cabinets have sufficient amounts of personal hygiene product which is provided by the licensee.
Bathrooms were checked for cleanliness and proper operation. The hot water temperature measured between 114.6 F and 115.1 F degrees in resident bathrooms.

Infection Control: Licensee states that staff wash their hands after taking gloves off but does not wash hands prior to placing gloves on. Technical violation issued.

Medications are centrally stored in locked storage cabinets behind the living room. Medications are properly labeled and checked for expiration dates. A sampling of residents’ medicationa show they are centrally stored prescription and PRN medication which have been logged in the medications record with proper documentation from the residents’ doctors. Proper medication dispensing instructions are followed and checked for contamination. First Aid kit has all proper items and is current.


Resident records were reviewed for requirements and legibility: LPA reviewed 5 residents’ files for Medical Assessments, Needs and Service plans, Signed Admission Agreements and Pre-appraisals. One resident needs their Appraisal, Needs & Services Plan signed, and dentist information entered on their Identification and Emergency Information sheet. Another resident who moved in last week needs an Appraisal, Needs & Services Plan completed. Licensee will ensure these items are complete and send to LPA by 8/23/23. Planned activities are offered to residents in care.
Staff records were checked for expired or missing certificates and clearances: LPA conducted a file review of 5 staff for criminal record clearances/associations and current First Aid. S1 did not have a background clearance. LPA instructed Licensee to have S1 leave the property and return only when clearance has been obtained. Deficiency cited, civil penalty issued. The first aid certification for Staff #2 (S2) expired on 11/20/22. Deficiency cited. Five out of five staff records reviewed indicate annual training was not completed. Deficiency cited. The Administrator file was reviewed for current first aid, fingerprint clearance, administrator certificate.
Continued on 809-C.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2023
LIC809 (FAS) - (06/04)
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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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ROSE GARDEN
FACILITY NUMBER: 405802285
VISIT DATE: 08/16/2023
NARRATIVE
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Quarterly emergency disaster drills have not been completed. Records show a drill was conducted on 7/15/23 and no prior documentation on drills. Deficiency cited.
Emergency Disaster Plan has an incomplete Section C, page 6. Technical violation issued. Licensee states the facility had a bus to transport residents, however, they no longer have the bus and would transport residents in an emergency with staff vehicles. Emergency disaster plan needs to be updated to reflect as such. Technical violation issued.
Facility has two residents using oxygen with tanks in their rooms. Signage is present, however, Licensee states the fire department has not yet been notified. Technical violation issued. Licensee will notify the fire department and send documentation to LPA by 8/23/23.
Liability Insurance: Licensee states she has liability insurance but does not have documentation showing the coverage. Deficiency cited. Licensee will send LPA proof of liability insurance by 8/23/23.

Exit interview conducted, deficiencies cited, and civil penalty given, technical violations issued, and the report and appeal rights given.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2023
LIC809 (FAS) - (06/04)
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