Rose Garden Residential Care

Licensing Program Analyst (LPA) Bernadette Allen an conducted an unannounced visit to initiate and deliver a complaint investigation for the allegation above. LPA Allen met with Danica Turner who was informed of the purpose of the visit. The investigation consisted of observations, interviews with staff members and administrator Danica Turner who stated resident 1 (R1) was in the dining hall and last seen around 2:45 AM. Staff 1 (S1) noticed resident 1 (R1) was not in the dining area. S1 contacted the other two (2) staff members informing them that R1 was missing and requested that a tour of the facility be done inside and outside of the facility to locate R1. While touring the outside area at the main entrance (S1) noticed a free-standing wheelchair where the resident jumped over a fence. S1 canvased the neighborhood and R1 was found at Jack in the Box around 3:20AM where she was being interviewed by the police. S1 identified themselves and the facility that R1 eloped from and was escRead the full finding— CDSS inspection report, December 6, 2023 · control 56-AS-20231128111534

Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to initiate and deliver findings for the mentioned allegations. LPA Allen met with Leilani Cortez Wellness Director who was informed of the purpose of the visit and allegations. LPA Allen conducted interviews with staff members and outside parties who stated not all of resident 1's (R1) personal items were not provided upon discharge. During LPA visit there was one (1) personal item located. The interviews with staff members stated that R1 glasses were taped but they could not confirm or deny if the glasses were broken or if R1's authorized representative was notified. LPA did observe that glasses were broken and outside parites stated that R1's glasses were broken upon arrival. Based on the evidence gathered during the investigation,the above allegation is found to be Substantiated. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence stRead the full finding— CDSS inspection report, November 16, 2023 · control 56-AS-20231115085745

Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to initiate and deliver findings for the mentioned allegations. LPA Allen met with Leilani Cortez Wellness Director who was informed of the purpose of the visit and allegations. LPA Allen conducted interviews with staff members, Resident 1 (R1), outside parties and documents were reviewed. The interviews conducted with staff members stated that residents are check on every two (2) hours or as needed. Staff has also stated R1 could use the restroom as needed but had to be encouraged allowing staff to check their undergarments due to incontinence. Staff also stated they have not experienced any resident being soiled for an extended period. Records were reviewed and it appeared that there is adequate staff to meet the needs of the residents. Records reviewed also shows residents hygiene needs are met daily or as needed. During the visit LPA observed residents in care clothing to be free of stains, odors and thRead the full finding— CDSS inspection report, November 16, 2023 · control 56-AS-20231115085745

Licensing Program Analyst (LPA) Bernadette Allen an conducted an unannounced visit to initiate and deliver a complaint investigation for the allegation above. LPA Allen met with Danica Turner who was informed of the purpose of the visit. The investigation consisted of observations of several beds, interviews with staff, residents, and record review. The interviews with residents have stated their beds are free of bed bugs. The interviews with staff stated there have been ongoing treatments for bedbugs which seemed to be resolved. LPA also observed documentation from the pest control that confirms the licensee has taken measures to resolve any issues with bedbugs. LPA also toured the facilities bedrooms H, E, J and Private Room and each bed appeared to be free bedbugs. Based on observations, interviews, and documentation the above finding is Unsubstantiated. UnsubstantiatedRead the full finding— CDSS inspection report, November 6, 2023 · control 56-AS-20231102131314

Licensing Program Analyst (LPA) Bernadette Allen made an unannounced visit to deliver the findings for the complaint investigation. LPA met with Leilani Cortez-LVN and she was informed of the purpose of today’s visit. The investigation consisted of interviews with staff members,residents responsible parties and the residents facility files. Allegation #1 Facility did not take necessary steps to prevent a scabies outbreak: LPA conducted interviews with facility staff, administrator Danica Turner, and responsible parties of residents. The interviews with the staff and responsible parties have stated there are no residents at the facility that has been diagnosed by a physician with having scabies. LPA also observed residents files and there was no record or diagnosis of any residents having scabies. During the investigation the LPA was informed of the procedures if there was an diagnosis/outbreak of scabies. UnsubstantiatedRead the full finding— CDSS inspection report, October 30, 2023 · control 56-AS-20230823155415

Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to deliver findings for the allegations above. LPA Allen met with Leilani Cortez-LVN who was informed of the purpose of the visit. The investigation consisted of interviews with staff members, outside parties, and review of Resident 1 (R1) medical records and facility file. The interviews with staff members stated they did not see R1 fall outside they only observed R1 laying on the ground and could not explain how the bruising/scars happened. There were no witnesses that could confirm if the resident fell resulting in unexplained bruising. LPA observed pictures and reviewed medical records that reflect there were bruises and scares on the face and wrist of R1 that could not be explained. LPA did attempt to interview R1on 9/18/2023, but they were at a doctor's appointment. Based on LPA observations, documentation and interviews the above allegation is found to be Substantiated. SubstantiatedRead the full finding— CDSS inspection report, October 30, 2023 · control 56-AS-20230912084226

Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to deliver findings for the allegation above. LPA Allen met with Leilani Cortez-LVN who was informed of the purpose of the visit. On10/30/2023 LPA observed Resident 1's (R1) room to be clean and free of odors. LPA also observed R1's bed linen to be clean, free of stains and orders. LPA observed documentation that reflects there is a schedule in place for R1’s weekly hygiene needs or as needed to be met. The interviews with the staff members stated that the residents have schedule for showers twice a week or as needed daily. LPA attempted to have a conversation with R1, but they were not willing to communicate during the visit however LPA did observe R1’s hygiene need seemed to be met, R1’s hands/nails were free of debris, clean clothing free of stains and odors. UnsubstantiatedRead the full finding— CDSS inspection report, October 30, 2023 · control 56-AS-20230912084226

Licensing Program Analyst (LPA) Bernadette Allen an conducted an unannounced visit to initiate and deliver findings for the allegations above. LPA Allen met with Dicina Turner Administrator who was informed of the purpose of the visit. LPA attempted to interview six (6) residents (R1, R2, R3, R4, R5 and R6) who could not confirm of deny that their personal rights had been violated by not being allowed to have a clean room, visitors not being allowed, not being properly groomed,staff not providing adequate supervision, being retaliated against, unlawfully being evicted and not properly feed. LPA interviewed six staff members (S1, S2, S3, S4, S5 and S6) and all staff members stated that they have not witnessed any of the client’s personal rights being violated by not being allowed to have a clean room, visitors not being allowed, not being properly groomed, staff not providing adequate supervision, being retaliated against, unlawfully evicted and not being properly feed. During the visitRead the full finding— CDSS inspection report, October 2, 2023 · control 56-AS-20230927090814

Licensing Program Analyst (LPA) Bernadette Allen made an unannounced visit to deliver findings for the mentioned allegations. LPA met with Danica Turner Administrator who was informed of the purpose of the visit. The investigation consisted of interviews with an outside party, One (1) staff member, review of R1's medical records and facility file. LPA interviewed S1 who stated that R1's files were up to date when R1 move into the facility back 2019. LPA reviewed R1’s medical discharge documents and R1's facility files LPA did not observe any future appointments, prescriptions, or treatments and the facility file appeared to be current. The interviews with R1’s responsible party and outside party revealed that there were no future required appointments, prescriptions, or treatments stated on the hospital discharge papers. Interviews also revealed that Innovage and/or R1's responsible party is responsible for scheduling appointments unless immediate medical attention is required and thenRead the full finding— CDSS inspection report, August 22, 2023 · control 56-AS-20230802153622

Licensing Program Analysts (LPA) Bernadette Allen arrived at the facility unannounced to deliver the findings for the allegation listed above. LPA met with Morgan Williams Administrator. Interviews were conducted with 1 Client (C1), 1 Staff (S1), 2 Two outside parties (2 OP), documents were reviewed, and observations of Client #1. LPA observed bruises on (C1) arms and when asked what happened they said I banged them up. Records revealed that (C1) has behavior episodes and some medication(s) taken can contribute to bruising. The interviews with the (2 OP) and (S1) said that (C1) does have a history of behavior episodes that may cause harm to themselves and others. UnsubstantiatedRead the full finding— CDSS inspection report, June 21, 2023 · control 56-AS-20230602144800

Licensing Program Analyst (LPA) Bernadette Allen made an unannounced visit to initiate a complaint investigation for the allegations above. LPA met with Morgan Williams who was informed of the purpose of our visit and allegations. LPA toured the facility and observed sufficient staffing, LPA interviewed 9 staff members who said that there is sufficient staffing to care for the residents. LPA also observed documents that show that there has been sufficient staffing for the clients at the facility. During the tour of the facility LPA observed that precautions have been taken to stop the residents from throwing personal items over the gate. Morgan has also stated additional fencing will be put in place to ensure that all residents personal items will remain on their property. Based on the interviews, observations and record reviewed the above findings is Unsubstantiated. A finding of unsubstantiated means although the allegations may have happened or is valid, there is not a preponderanceRead the full finding— CDSS inspection report, June 21, 2023 · control 56-AS-20230616143432

Licensing Program Analyst (LPA) Bernadette Allen made an unannounced visit to initiate and deliver the findings for this complaint investigation. LPA met with Morgan Williams and discussed the purpose of today’s visit. The investigation consisted of interviews with seven (7) residents, and nine (9) staff members. Allegation #1 Facility did not take necessary steps to prevent a scabies outbreak: LPA interviews with facility staff, administrator Morgan Williams, and wellness director Casandra Crowley all stated there are no residents at the facility that has been diagnosed by a physician with having scabies. LPA interviewed 7 seven residents and 4 four residents stated that they don’t have a rash or scabies. Three 3 residents said that they have a rash, but they were not diagnosed as having scabies. During the interviews the wellness director she stated that if there was diagnosis /outbreak of scabies individual(s) would be isolated, staff would provide environmental disinfection and medRead the full finding— CDSS inspection report, June 21, 2023 · control 56-AS-20230613150538

Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to initiate an investigation and deliver finding for the allegations listed above. LPA Allen met with Morgan Williams and explained the reason for the visit. During the investigation One (1) Resident and Two (2) staff members were interviewed. (R1) was asked about sustaining injuries while at the facility by someone or something and resident (1) said they had not been hurt by anything or anyone while at the facility. (R1) was asked about their personal belonging and (R1) said that they have what they need. During the investigation LPA Allen did observe personal hygiene items and clothing items in (R1's) room as well as the required furniture was which appeared in good condition. Based on documenst reviewed the resident is capable of handling their personal hygiene needs and when (R1) was asked about their hygeine needs it was said that they can shower whenever they want to shower. UnsubstantiatedRead the full finding— CDSS inspection report, January 27, 2023 · control 56-AS-20220824151817

Licensing Program Analyst (LPA) Bernadette Allen an conducted an unannounced visit to initiate and deliver findings for the allegations above. LPA Allen met with Morgan Williams who was informed of the purpose of the visit. During LPA Allen investigation, LPA interviewed five (5) staff member and five (5) residents. LPA Allen interviewed (R1) who said that they don’t have bruising on their body and that they don't have any problems with people. LPA also observed documentation that shows staff members have been documenting when bruising occurs on the residents. The interviews conducted with the five (5) staff members said that there are times when confrontations occur with residents and they are redirected and one on one staff supervision is put in place if needed. Documents were reviewed and staff are taking precautions to prevent altercations between residents. UnsubstantiatedRead the full finding— CDSS inspection report, January 25, 2023 · control 56-AS-20230118111439

Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to this facility for the purpose of initiating a complaint investigation and delivering findings on the above allegation. LPA met with Morgan Williams and she was informed of the purpose of the visit Allegation- The air conditioning unit was not working. The investigation consisted of observations, staff interviews, and pertinent documents. Upon arrival LPA Allen observed maintenance work being done to outside of the facility at the main entrance. Morgan Williams stated that the maintenance director came out the same day to assess the AC Unit and it was determined that a new AC unit was required. In the meantime, a portable generator was purchased and observed outside attached to the kitchen area. LPA Allen observed fans placed throughout the main dining area until the power was restored on 9/3/2022. UnsubstantiatedRead the full finding— CDSS inspection report, December 14, 2022 · control 56-AS-20220906150629

Licensing Program Analysts (LPA) Bernadette Allen arrived at the facility unannounced to conduct a complaint investigation and deliver the findings for the allegation(s) listed above. LPA met with Morgan Williams Administrator. During visit LPA Allen, conducted interviews and record reviews and found the following Allegation #1- Medication not being dispensed to resident. LPA, Allen conducted interviews with three (3) staff members and reviewed resident(s) files and LPA found that medications were being dispensed to the resident(s) in care. Allegation #2- Denied entry to visit resident. LPA Allen interviewed outside party(s) and three (3) staff members and LPA found that the resident(s) visitor(s) were not denied entry into the facility. Allegation #3- Resident not assisted with ADLs. LPA Allen reviewed file(s) and R#1 handles their own ADL's and does not need care and supervision. UnsubstantiatedRead the full finding— CDSS inspection report, November 16, 2022 · control 56-AS-20221108110403

Licensing Program Analyst (LPA) Bernadette Allen an conducted an unannounced visit to initiate a complaint investigation for the allegations above. LPA Allen met with Morgan Williams who was informed of the purpose of the visit. First allegation state that staff did not ensure resident's grooming needs were met. During the investigation the LPA interviews with four (4) staff members, one (1) outside source and observations LPA Allen observed staff members were ensuring that the residents grooming needs are being met. LPA observed residents being cared for during the visit. Second allegation states that the residents are not adequately fed. During the investigation LPA Allen interviews and observation, the residents in care are being adequality feed by the staff. During the visit LPA observed a menu for the week and there is sufficient food supplies to met the needs of those in care. continued...... UnsubstantiatedRead the full finding— CDSS inspection report, September 14, 2022 · control 56-AS-20220906172953

Licensing Program Analysts (LPA) Bernadette Allen conducted an unannounced visit to this facility to deliver findings on the above allegation. LPA met with Morgan Williams and informed her of the purpose of the visit. The investigation consisted of interviews with facility and outside parties. Interviews conducted with facility staff revealed that when the facility phone rings the staff does answer it. If a call is missed then the staff will call the person back. Interview conducted with an outside party stated that whenever the facility is contacted via phone call, the staff answers the phone. LPA observed during todays visit that the facility's phone is operational and calls were being answered by staff. There were no witnesses or enough eveidence to corroborate the above allegation. Based on the investigation, the above finding is Unsubstantiated. A finding of unsubstantiated means although the allegations may have happened or is valid, there is not a preponderance of evidence to prRead the full finding— CDSS inspection report, August 3, 2022 · control 56-AS-20220715164531

Licensing Program Analyst (LPA) Stephanie Williams made an unannounced visit to the facility in order to deliver finding for the above allegations. LPA Williams identified herself to Administrator, Morgan Williams, who was also informed of the purpose of the visit. The investigation consisted of records review and interviews with staff, witnesses, and residents. On 7/3/2020, Resident #1 (R1) experienced an accidental fall. Department staff interviewed Staff #1 (S1) and Staff #2 (S2), who both stated that S2 was present as R1 experienced the fall. According to S1, S2 was in R1’s bedroom to pass out medications. S2 had asked R1 if R1 wanted to sit down, but R1 refused. S2 stated that as they were exiting R1’s bedroom, R1 tried to walk but tripped on their own feet. S2 stated that R1 fell down to the floor on R1’s right side in a seated position. S2 stated that they called for help from another caregiver to assist R1 back to bed. An assessment of R1 was conducted after R1 complained of hiRead the full finding— CDSS inspection report, March 7, 2022 · control 18-AS-20201013110332

Licensing Program Analysts (LPAs) Anna Bueno and Bernadette Allen conducted a complaint visit to deliver findings on the above allegations. LPAs met with Executive Director (ED), Morgan Williams and Cindell Graham, Wellness Director. LPA Bueno conducted the initial investigation and interviewed staff and reviewed facility files. The first complaint alleges that staff do not report incidents as required. Community Care Licensing regional office has been receiving and recording incident reports from the facility consistently. The second complaint alleges that staff did not prevent residents from engaging in a physical altercation. Per observations and interviews, staff are always present in areas where residents congregate and attend to a resident when flagged or when resident asks for assistance. The third complaint alleges that resident medication UnsubstantiatedRead the full finding— CDSS inspection report, November 24, 2021 · control 18-AS-20210825144027

Licensing Program Analysts (LPAs) Anna Bueno and Bernadette Allen conducted a complaint visit to deliver findings on the above allegations. LPAs met with Executive Director (ED), Morgan Williams and Cindell Graham, Wellness Director. LPA Bueno conducted the initial investigation and interviewed staff and resident and reviewed facility files. The first and second allegations state that Resident 1 (R1) was was improperly restrained and yelled at by staff. Interviews with staff and resident revealed that R1 is combative when being changed. Interviews also confirmed that there is always at least two care staff assisting in changing R1 because they would complain of pain when being changed. The third allegation is that the facility is not kept clean. LPA toured the facility and viewed several resident rooms in all three buildings. Through interviews and observations, LPA determined that cleaning supplies are accessible to staff in all shifts and housekeeping is conducted daily in common rooRead the full finding— CDSS inspection report, August 30, 2021 · control 18-AS-20210825144027

Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility to investigate the above allegations. LPA met with Administrator Morgan Williams and Cindell Garham, Wellness Director. LPA toured the facility, conducted interview, and made pertinent observations. The first allegation indicates that the facility phone is in disrepair. LPAa was informed that the facility had a brief intermittent phone and wifi issues while their communications provider tested equipment in the facility. LPA observed four answered calls made to the facility during today's visit. The second allegation indicates that the staff was not allowing family visitations. LPA observed an ongoing outdoor visit with a resident and LPA observed a resident on their way to an outing. LPA also observed a visitation appointment book with appointments from Agust 2020 Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did oRead the full finding— CDSS inspection report, August 23, 2021 · control 18-AS-20210820153948

Licensing Program Analyst (LPA) Christine Le conducted an unannounced visit to the facility to investigate the above allegations. LPA met with Executive Director Morgan Williams. LPA conducted interviews and reviewed facility files. The first allegation indicates that the facility did not ensure Resident 1 (R1) was provided medications upon leaving the facility. LPA was informed that on 6/29/20 R1 sustained a fall at the facility and was hospitalized due to hip pain. After the hospital, R1 was transferred to a SNF. The allegation indicates that the facility staff did not provide R1's medication list to the hospital and/or SNF. LPA reviewed the facility documentation and observed that the facility staff sent R1's medication list to the hospital and SNF. The second allegation indicates that the facility staff did not safeguard R1's personal belongings. LPA was informed that after R1's hospitalization and rehabilitation at the SNF, R1 and his/her family member decided to move the residentRead the full finding— CDSS inspection report, August 19, 2021 · control 18-AS-20200904114901

Licensing Program Analyst (LPA) Elecia Weathersby made an unannounced visit to initiate a complaint investigation for the above allegations. LPA met with Administrator Morgan Williams to discuss complaint investigation and deliver findings. Allegation #1 - Facility does not have sufficient staff The investigation consisted of facility inspection, interviews with facility administrator, and review of facility records. LPA obtained copies of pertinent documents. It was revealed that there is a sufficient number of qualified staff to meet the needs of the residents in care, for all shifts. This agency has investigated the complaint allegation. We have found that the preponderance of evidence standard was not met, therefore the above allegation is UNSUBSTANTIATED. A finding of Unsubstantiated means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy ofRead the full finding— CDSS inspection report, July 23, 2021 · control 18-AS-20210415154729

Licensing Program Analyst (LPA) Stephanie Martinez conducted a visit to deliver an amended report of previous findings delivered by LPA Elecia Weathersby. LPA Weathersby conducted an investigation of the above stated allegations. During the investigation LPA Weathersby met with Administrator Morgan Williams, conducted interviews with staff, Resident 1 (R1), other pertinent witnesses and conducted a review of facility records. Allegation #1 - Staff failed to contact authorized representative in a timely manner. LPA Weathersby reviewed records, conducted interviews with staff, resident 1 (R1) and confidential witness. It was alleged that the responsible party was not notified of R1's diagnosis. Administrator Williams stated R1’s responsible party had been notified of the diagnosis. LPA was unable to corroborate or refute the allegation. Allegation #2 - Facility not safeguarding residents’ belongings. LPA Weathersby conducted interviews with staff, (R1) and confidential witness. It was alRead the full finding— CDSS inspection report, July 23, 2021 · control 18-AS-20210714112954