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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202528
Report Date: 09/25/2024
Date Signed: 09/25/2024 04:49:01 PM

Unfounded


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
10/31/2023 and conducted by Evaluator Simranjit Rai
COMPLAINT CONTROL NUMBER: 26-AS-20231031142449
FACILITY NAME:JULIETTE'S GARDENS (ROSE)FACILITY NUMBER:
435202528
ADMINISTRATOR:PEREZ, JONATHANFACILITY TYPE:
740
ADDRESS:1511 ILIKAI AVETELEPHONE:
(408) 393-3882
CITY:SAN JOSESTATE: CAZIP CODE:
95118
CAPACITY:6CENSUS: 5DATE:
09/25/2024
UNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Lead Caregiver, Lisa (Noveliza) ManzanillaTIME COMPLETED:
04:40 PM
ALLEGATION(S):
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Licensee did not ensure residents records are complete and current.
Staff does not have 40 hours of required training
The facility is not meeting residents Recommended Dietary Allowance.
Facility placed cameras in the facility without the residents/ responsible party's consent.
Staff assisting residents with self-administration of medication do not have required medication training.
Facility not providing activities which foster and maintain independent functioning
Facility has rodents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with the Administrator and stated the purpose of today’s visit.

On 10/31/2023 the Department received a complaint with the above allegations. On 11/6/2023, the Department conducted an initial investigation at the facility.


Continuation on LIC 9099-C, Page 1 of 4.


Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024
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 8
Control Number 26-AS-20231031142449
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: JULIETTE'S GARDENS (ROSE)
FACILITY NUMBER: 435202528
VISIT DATE: 09/25/2024
NARRATIVE
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Page 2 of 4.

Licensee did not ensure residents records are complete and current. /Staff does not have 40 hours of required training. / Staff assisting residents with self-administration of medication do not have required medication training.

On 11/6/2023, the LPA reviewed 3 staff files and 3 resident files. All files were complete and current, including the required training for staff and medication training. Administrator (ADM) worked on R1 and R3’s physician to update LIC 602A’s Physician’s Order at the time of the visit. This was a plan of correction ADM was working on as a result of a deficiency cited during facility’s annual inspection on 9/21/2023.


Facility placed cameras in the facility without the residents/responsible party’s consent.

On 9/21/2023, during the facility’s annual inspection, LPA observed cameras in resident’s rooms which were placed without resident’s consent. ADM’s plan of correction was to remove the cameras until written consent was provided by resident and/or resident’s responsible party.

On 11/6/2023, the Department interviewed ADM. ADM stated on 9/21/2023, after facility’s annual inspection, ADM removed all cameras in the facility. During visit on 11/6/2023, the LPA did not observe any cameras at the facility.


The facility is not meeting residents Recommended Dietary Allowance.

On 11/6/2023, the Department interviewed two staff (S1-S2) and ADM. Three out of three staff stated there is an established food menu which accounts for resident’s requests and any special diets the residents require based on the physician’s order.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 26-AS-20231031142449
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: JULIETTE'S GARDENS (ROSE)
FACILITY NUMBER: 435202528
VISIT DATE: 09/25/2024
NARRATIVE
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Page 3 of 4.

On 11/6/2023, the Department interviewed 3 residents. Three out of three residents stated the food was okay and they did not have any complaints regarding the food served at the facility.

During the visit on 11/6/2023, the LPA observed the facility food supply where the facility had a variety of food, including fruits, vegetables, and canned foods. LPA also observed lunch service and residents were served chicken pot pie and a bowl of fruit.


Facility not providing activities which foster and maintain independent functioning.

On 11/6/2023, the Department interviewed two staff (S1-S2) and ADM. Three out of three staff stated the facility staff provide activities such as walks, playing cards, read books, watch tv or sports. Staff S1 stated the residents have physical therapist visitations at the facility and staff will encourage the residents to exercise their arms and legs. Staff S2 stated the staff will interact and mingle with the residents as well.

On 11/6/2023, the Department interviewed 3 residents. Two out of the three residents stated the facility provide activities and they are satisfied with activities provided. One out of the three residents did not answer any questions regarding facility providing activities.

During the visit on 11/6/2023, the LPA did observed residents watching tv and later observed staff S1 take resident R1 and R2 for a walk outside of the facility.


Facility has rodents.

On 11/6/2023, the Department interviewed two staff (S1-S2) and ADM. Three out of three staff stated they have not seen any rodents in the facility and have not heard of the residents complain or mention seeing rodents in the facility.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 26-AS-20231031142449
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: JULIETTE'S GARDENS (ROSE)
FACILITY NUMBER: 435202528
VISIT DATE: 09/25/2024
NARRATIVE
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Page 4 of 4.

On 11/6/2023, the Department interviewed 3 residents (R1-R3). Three out of three residents stated they have seen or heard any rodents in the facility.

During the visit on 11/6/2023, the LPA toured the facility and did not observe rodents or rodent feces/droppings.

The Department has completed the investigation of the above allegations. Based on interviews conducted and record reviews, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis.

No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Administrator and a copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 8
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
10/31/2023 and conducted by Evaluator Simranjit Rai
COMPLAINT CONTROL NUMBER: 26-AS-20231031142449

FACILITY NAME:JULIETTE'S GARDENS (ROSE)FACILITY NUMBER:
435202528
ADMINISTRATOR:PEREZ, JONATHANFACILITY TYPE:
740
ADDRESS:1511 ILIKAI AVETELEPHONE:
(408) 393-3882
CITY:SAN JOSESTATE: CAZIP CODE:
95118
CAPACITY:6CENSUS: 5DATE:
09/25/2024
UNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Lead Caregiver, Lisa (Noveliza) ManzanillaTIME COMPLETED:
04:40 PM
ALLEGATION(S):
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Facility is not ensuring infection control practices are followed
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with the Administrator and stated the purpose of today’s visit.

On 10/31/2023 the Department received a complaint with the above allegations. On 11/6/2023, the Department conducted an initial investigation at the facility.

On 11/6/2023, the Department interviewed two staff (S1-S2) and ADM. Three out of thre staff stated in October 2023, two out of three residents had scabies. ADM stated the residents were provided with medication to treat the scabies. S2 stated the staff did not get the scabies infection while taking care of the residents.

Continuation on LIC 9099-C, Page 1 of 2.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 26-AS-20231031142449
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: JULIETTE'S GARDENS (ROSE)
FACILITY NUMBER: 435202528
VISIT DATE: 09/25/2024
NARRATIVE
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Page 2 of 2.

Based on facility file, the facility has an Infection Control plan in place to manage outbreaks and other infections in the facility.

During today's visit, LPA Rai interviewed two staff (S1-S2). Two out of two staff were able to provide information regarding facility's infection control policy, cough etiquette and hand washing procedure.

During today's visit, LPA Rai observed a third party vendor who was disinfecting the facility, including but not limited to resident bedrooms, bathrooms, living room, kitchen, and outdoor space.

Based on the interviews conducted with clients and staff and based on observation and records review, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the above allegations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Administrator and a copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 8
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
10/31/2023 and conducted by Evaluator Simranjit Rai
COMPLAINT CONTROL NUMBER: 26-AS-20231031142449

FACILITY NAME:JULIETTE'S GARDENS (ROSE)FACILITY NUMBER:
435202528
ADMINISTRATOR:PEREZ, JONATHANFACILITY TYPE:
740
ADDRESS:1511 ILIKAI AVETELEPHONE:
(408) 393-3882
CITY:SAN JOSESTATE: CAZIP CODE:
95118
CAPACITY:6CENSUS: 5DATE:
09/25/2024
UNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Lead Caregiver, Lisa (Noveliza) ManzanillaTIME COMPLETED:
04:40 PM
ALLEGATION(S):
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Facility is not reporting incidents which threaten welfare, safety or health of residents within 7 days of occurrence
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with the Administrator and stated the purpose of today’s visit.

On 10/31/2023 the Department received a complaint with the above allegations. On 11/6/2023, the Department conducted an initial investigation at the facility.

On 11/6/2023, the Department interviewed ADM. ADM stated he did not submit incident reports to the Department regarding resident being hospitalized after a fall in August 2023 and when two out of three residents had scabies at the facility in October 2023.

Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 9099-D.
This report was reviewed with Administrator and a copy of the report was provided. Appeal Rights was provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 26-AS-20231031142449
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: JULIETTE'S GARDENS (ROSE)
FACILITY NUMBER: 435202528
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/02/2024
Section Cited
CCR
87211(a)(1)
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87211 Reporting Requirements
(a) (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events...
This requiement is not met as evidenced by:
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Administrator was not present during today's visit. Administrator stated to submit a written plan of action understanding regulation and ensure Incident Reports are submitted to licensng agency by POC due date.
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Based on interview and record review, ADM did not ensure to report was submitted to the licensing agency when resident being hospitalized after a fall and when two out of three residents had scabies at the facility which poses/posed a potential health, safety or personal rights risk to persons 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: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024
LIC9099 (FAS) - (06/04)
Page: 8 of 8