Rose Garden Court

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced to conduct a Case Management-Annual Continuation. The is a continuation of the annual inspection that was conducted on 11/20/2025, during which only the physical plant was inspected due to time constraints. LPA met with Administrator (ADM) Michael Rosete. Licensee Lilette Rosete joined the inspection at approximately 3:15PM. During today's visit, LPA reviewed 3 resident files, 3 staff files, and 3 residents Centrally Stored Medication and Destruction Records (CSMDRs). During review of Resident R3's CSMDR with the ADM, LPA observed R3's centrally stored log was not updated. ADM updated R3's medications on the CSDMR during the visit. LPA advised to ADM to ensure staff are documenting and updating residents centrally stored logs in a timely manner. A Technical Assistance was issued, see LIC9102. LPA reviewed the facility's emergency drill logs. The facility's last emergency drill was conducted on 9/2/2025. No deficiencies were cited during today's visit. A Technical Assistance was issued, see LIC9102 for more information. An Exit Interview was conducted with the ADM and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 1, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced annual inspection and met with Administrator (ADM) Michael Rosete. LPA stated the purpose of the visit. Licensee Lilette Rosete arrived at approximately 4:00PM. LPA toured the interior and exterior of the facility with ADM to include the kitchen, resident rooms, dining room, bathrooms, back and front of the facility. All exit and passageways were free and clear of obstruction. LPA toured the kitchen area and observed a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. The facility was equipped with smoke and carbon monoxide detectors. All smoke detectors functioned properly when tested by ADM. Fire extinguishers were last serviced on 3/11/2025. LPA toured 14 resident bedrooms, and observed 14 bedrooms to have a bed, functioning lights, dresser/table, bedding and space for personal belongings. LPA toured 14 bathrooms. All bathrooms had hand soap, paper towels, functioning lights, and covered trash bins. LPA measured water temperature with a range of 105 F to 115.7 F. Due to time constraints, this annual inspection will be continued at a later date. No deficiencies were cited during today's visit per California Code of Regulations Title 22. An exit interview was conducted with ADM and a signed copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 20, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to conduct a case management - other visit. LPA met with Licensee, Michael Rosete. The purpose of the visit was to amend a complaint report for complaint control number 26-AS-20250205155405. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Licensee, Michael Rosete and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jul 15, 2025

Allegation investigated: Staff did not ensure that facility is free from insects or rodents.

THIS IS AN AMENDED REPORT. On 05/14/2025, Licensing Program Analyst (LPA) Santino Fortes arrived to the facility unannounced to deliver the complaint investigation findings for the above allegation. LPA met with Licensee, Michael Roste. On 2/5/2025 the Department received a complaint with the above allegation. On 2/14/2025 the Department conducted the initial unannounced complaint investigation. LPA interviewed staff and residents. LPA conducted a facility file review. Based on observations, LPA inspected the facility inside and out to include resident rooms, common rooms, kitchen and food pantry. LPA did not observe any insects or pests. LPA interviewed 3 out of 3 staff (S1, S2, S3) who stated that they have not observed insects/pests in the facility and see exterminators periodically fumigating the facility. 5 out of 6 residents (R2, R3, R4, R5, R6) interviewed stated that they have not seen insects in the facility and see exterminators regularly fumigating the facility. See LIC9099-C pages for more information. Page 1 of 2. Unsubstantiated 1 out of 6 residents (R1) stated to have killed a cockroach inside his/her bedroom but could not provide proof because no picture was taken. Based on observation of R1's bedroom, there were no observation of any cockroaches or other insects. Based on document review, the licensee is taking measures to ensure the facility is free from pests as the licensee has an annual extermination service to prevent pest in the facility. The Department has investigated the above allegation. Based on interview, record review and observation the above allegation is unsubstantiated. An unsubstantiated finding indicates that although the allegation listed above may have happened or was valid, there is not a preponderance of evidence to prove the allegation did or did not occur. No deficiencies were cited per California Code of Regulations (CCR), Title 22. An exit interview was conducted and was reviewed with Administrator Michael Rosete and a copy of this report was provided. Page 2 of 2.the state’s words, verbatim · CDSS document, May 14, 2025 · control 26-AS-20250205155405

Allegation investigated: Staff are not following a resident's dietary plan Staff are not assisting a resident with transferring from bed

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Michael Rosete. On 10/07/2024, the department received a complaint with the above allegations. On 10/11/2024, LPAs Fortes and Marrufo conducted an initial complaint investigation visit. LPA Marrufo obtained a copy of the Resident Roster, which indicates that R1 was admitted to the facility on 08/09/2024. LPA Marrufo obtained a copy of R1’s Physician’s Report, which is dated 07/30/2024. R1’s Physician’s Report has neither the “Yes” nor “No” columns checked in the row indicating if R1 has a special diet. The “Able to Feed Self” row is checked “No” and has the comment, “requires set up then able to feed self.” See LIC9099-C pages for more information. Page 1 of 5. Unsubstantiated LPA Marrufo obtained a copy of R1’s Appraisal/Needs and Services Plan (A/NS), dated 08/09/2024. The “Background Information” section of the A/NS states “with assistance with [his/her] ADLs (Activities of Daily Living) and Transfers.” The Functioning Skills section states “[R1] is independent.” The A/NS does not include details of R1’s needs related to ADLs, transfers, special diet, and feeding. R1’s A/NS Plan was signed by the facility Administrator/Licensee on 08/09/2024. The signature fields for the client/resident’s authorized representative are blank. LPA Marrufo obtained copies of R1’s Progress Notes written by R1’s Speech Therapist. The Progress Note from 08/16/2024 states “Avoid bread items, except for very soft and moist textures like banana bread cut on to bite size.” The Progress Note from 08/28/2024 states “Pls (sic) provide feeding assistance & offer water every hour until pt can feed [him/her]self independently.” The Progress Note from 09/06/2024 states, “Downgrade diet level to soft + bite sized texture as pt eats alone sometimes & pt may self-feed large bites w/o supervision. ** No Bread.” The Progress Note from 09/16/24 states, “Pls make sure to avoid bread items – pancakes, toast, etc.” The Progress Note from 10/04/2024 at 11:10 states, “Pls make sure pt receiving safe & bite-sized texture only. Pt choked today. It can happen again. Avoid all breads. Pls refer to the soft & bite-sized handout if needed.” During visit on 10/11/2024, LPA Marrufo interviewed R1. R1 stated to not have a special diet. R1 stated R1 requires food to be soft. R1 stated R1 likes food to be textured but does not require it to be. R1 stated staff always provide R1 with soft and textured food. R1 stated that R1 has chocked on food while at the facility. R1 stated to have chocked on big chunks of apple pie with a “rustic crust.” R1 stated R1’s speech therapist fed R1 the apple pie. R1 stated the speech therapist is not a staff of the facility. R1 stated the speech therapist feeds R1 to check R1’s swallowing and chewing. R1 stated the apple pie came from the facility kitchen. R1 states to not know why the staff did not cut up the apple pie into smaller pieces. During interview on 10/11/2024, facility manager M1 stated that R1 had a choking incident on 10/04/2024 at noon during lunch. M1 stated that R1’s meal came from the facility kitchen. M1 stated neither M1 nor the facility staff were told that R1’s Speech Therapist would be feeding R1. M1 stated R1’s order for soft and textured food came from home health and the facility does not have R1’s home health plan. M1 stated R1 is a manual feeder and can feed himself/herself independently. Page 2 of 5. M1 stated that R1’s Speech Therapist was feeding R1 and called the staff to let them know R1 was choking. M1 stated R1’s Speech Therapist called 911. M1 stated that when the paramedics arrived, they determined R1 was stable and did not want to take R1 to the emergency room. During interview on 10/11/2024, staff S1 stated that R1 needs bite-sized foods. S1 stated that R1’s Speech Therapist told S1 that R1 requires bite-sized food when R1 was admitted to the facility. S1 stated that S1 made notes in the kitchen that R1 needs bite-sized food. S1 stated that S1 uses a cutter to cut R1’s food and that when R1’s food leaves the kitchen, it is already cut to bite-size. S1 stated to have not observed R1 choking on food. S1 stated R1’s Speech Therapist reported to S1 that R1 was choking on R1’s food. S1 stated to have asked R1's Speech Therapist that if R1 was choking, then why was R1’s plate empty? S1 stated to have checked R1’s vitals and found R1’s vitals to be normal. S1 stated R1’s Speech Therapist called 911. During interview on 03/26/2025, R1’s Speech Therapist stated that R1’s home health plan was not at the facility. R1’s Speech Therapist stated that he/she would write Progress Notes after each visit with R1 and review the Progress Notes with the staff. R1’s Speech Therapist stated to have left a handout with staff that explained what kind of food qualified as bite-sized and soft. R1’s Speech Therapist stated that bite-sized food would be around the width of the average person’s thumb and soft food would be food that could be squished by placing a fork over the food and applying thumb pressure on top of the fork. If the fork can squish the food, then the food is considered soft. If not, then the food would be considered too hard and would need to be cooked further. R1’s Speech Therapist stated that he/she was in R1’s bedroom when R1 choked. He/she stated there were no staff in the room with him/her at that time. He/she stated that R1 was feeding himself/herself. R1’s Speech Therapist stated that R1 may have been eating either a spring roll or an apple pie, although he/she could not remember exactly. R1’s Speech Therapist stated R1 began to choke and he/she began to tell R1 to cough hard to clear R1’s throat. R1’s Speech Therapist stated no staff were nearby, so he/she decided to call 911 for R1. He/she stated that when paramedics arrived, R1 refused to go be taken to the hospital. Page 3 of 5. R1’s Speech Therapist stated that apple pie may or may not be considered soft food, depending on whether the apples are crispy or soft and if the crust can be crushed by a fork easily. During visit on 10/11/2024, LPAs Fortes and Marrufo observed R1 feeding himself/herself with a spoon that had an assistive foam grip while sitting in a wheelchair. R1 was observed to be eating ravioli and garlic bread that was cut into small pieces. During interview on 10/11/2024, R1 stated that staff transfer R1 out of bed and into R1’s wheelchair three times a day for meals. R1 stated that if R1 wishes to be transferred out of bed at other times, staff transfer R1 out of R1’s bed. R1 stated staff use a Hoyer lift to transfer R1 out of bed. R1 stated to have never been left in bed all day. During interview on 10/11/2024, M1 stated that R1 is never left in bed all day. During visit on 10/11/2024, LPAs interviewed 3 staff. 3 out of the 3 staff stated they assist R1 with transferring from R1’s bed to R1’s wheelchair. LPAs obtained copies of R1’s Wheelchair Transfer Record for September 2024 and October 2024. The logs record the times R1 was transferred to R1’s wheelchair in the morning, afternoon, and evening. Each day indicates R1 was either transferred twice in each morning, afternoon, and evening or refused to be transferred except on the evenings of 09/24-26/2024, which are blank. The October 2024 log has blank spaces on the evenings of 10/03-04/2024 and 10/08-11/2024 and the afternoons of 10/04/2024 and 10/9-11/2024. The rest of the times indicate either staff transferred R1 or R1 refused to be transferred. During interview on 03/26/2025, M1 stated that the blank spaces on the Wheelchair Transfer Logs must have been times when R1 was sleeping. M1 stated to have told the staff to write in the Remarks column of the Wheelchair Transfer Logs when the resident was sleeping, but the staff may not have written that R1 was sleeping. Page 4 of 5. Based on information from interviews conducted with staff, and records reviewed, although the allegations listed above may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are unsubstantiated. No Deficiencies were cited under California Code of Regulations Title 22. This report was reviewed with Michael Rosete and a copy of this report was provided. Page 5 of 5. END REPORT During interview on 03/26/2025, M1 stated to have called pest control on 10/11/2024 and pest control specialists visited the facility on the following Saturday. LPA obtained copies of the Pest Control Invoice that indicates pest control specialists arrived at the facility on 10/12/2024 to spray for cockroaches. On 10/11/2024, LPAs interviewed 3 other staff. 3 of the 3 interviewed staff stated to have not observed cockroaches at the facility. On 10/11/2024, LPAs interviewed 6 residents. 2 out of the 6 interviewed residents stated to have observed cockroaches at the facility. 4 out of the 6 interviewed residents stated to have not observed cockroaches at the facility. Based on records review, interviews and observations there is preponderance of evidence to prove the alleged violation did occur; therefore, the allegation is substantiated. See 9099-D for deficiencies cited per the California Code of Regulations, Title 22. This report was reviewed with Michael Rosete and a copy of this report and appeal rights were provided. Page 2 of 2. END REPORTthe state’s words, verbatim · CDSS document, Mar 26, 2025 · control 26-AS-20241007093238

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Mar 27, 2025

a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by: Licensee did not ensure that pest control services were contracted after cockroaches had been observed at the facility for at least ten days, which poses an immediate health risk to residents in care.the state’s words, verbatim · CDSS document, Mar 26, 2025

Plan of correction: Licensee agrees to maintain an ongoing contract with a pest control company to ensure regular spraying for cockroaches at the facility and submit an agreement for regular monthly spraying service with a pest control company to CCL by POC date.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Michael Rosete. The purpose of the visit was to cite the facility for deficiencies found during a complaint investigation that the department received on 10/07/2024. During the investigation, it was found that resident R1's Physician's Report did not have a "Yes" or "No" checked on the "Special Diet" row. R1's Appraisal/Needs and Services Plan does not detail the support R1 needs with Activities of Daily Living (ADL), transferring, special diets, and food requirements. R1's Appraisal/Needs and Services Plan does not have a signature from the client or resident's authorized representative. A deficiency was cited as per California Code of Regulations Title 22. See LIC809-D page for more information. This report was reviewed with Michael Rosete and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Mar 26, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Apr 2, 2025

(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement was not met as evidenced by: Licensee did not ensure that resident R1’s Physician’s Report had the “Special Diet” row checked either “Yes” or “No” and that R1’s Appraisal/Needs and Services Plan included details of R1’s needs related to Activities of Daily Living (ADLs), Transferring, Special Diet, and Food Preparation needs, as well as having the resident or resident’s representative’s signature and date, which poses a potential health risk to residents in care.the state’s words, verbatim · CDSS document, Mar 26, 2025

Plan of correction: Licensee agrees to review all resident Physician’s Reports and Appraisal/Needs and Services Plans and ensure that they are all complete, signed, and reflective of each resident’s health condition and care needs. Licensee agrees to submit copies of all current resident Physician’s Reports and Appraisal/Needs and Services Plans to CCL by POC date.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Santino Fortes and Simi Rai conducted an unannounced annual inspection and met with Caregiver (CG) Sam Sabangan. CG informed that facility has 3 staff and 12 clients. LPAs toured the facility inside/ out including: kitchen, Dining, family room and 1 staff room, 3 shared resident rooms and 2 common restrooms. Restrooms observed to have non-skid flooring. LPAs observed perishable food supply of at least two days and non-perishable food supply of at least seven days. Refrigerator temperature was observed at 40 degrees F and Freezer temperature was -5 Degrees F. During visit CG stored the dish soap with the sharps to correct. The front yard and backyard of the facility was also inspected. There was no obstruction to block the outdoor exits. An old washer and dryer were observed in the walkway and scheduled to be picked up for disposal. There was ample room for residents to pass in the event of an emergency. One storage shed was inspected to be storing old mattresses and bedding supplies. LPA observed Facility License and Resident Personal rights were posted. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to clients in care. Room temperature was at 73.5 degree F. LPA inspected the facility first aid kit and it was observed to be complete. The facility was equipped with smoke and carbon monoxide detectors. All smoke detectors functioned properly when tested. Fire extinguishers were last serviced on Feb 1, 2024. The facility conducted their last fire drill on 10/30/2024. LPA reviewed facility records for 5 staff and 8 clients. LPA reviewed 8 clients medications and centrally stored medication records. No deficiencies were cited during today's visit as per California Code of Regulations Title 22. Exit interview was conducted with CG. This report was reviewed and a copy was provided to CG.the state’s words, verbatim · CDSS document, Nov 25, 2024

Type of visit: Case Management - Health Checks

Licensing Program Analysts (LPAs) Simi Rai and Steve Chang arrived to the facility unannounced to conduct a case management visit to follow up on resident (R1) who was admitted after the previous facility was closed due to TSO (Temporary Suspension Order). LPAs met with Administrator, Michael Rosete. LPAs toured R1's room and observed bed with available bedding, a night stand and functioning lights. LPAs observed a bathroom attached to R1's room which had a working toilet, sink and functioning lights. LPAs toured the kitchen and pantry closet to observed 2 days of perishable foods and 7 days of nonperishable foods. LPAs spoke with R1. R1 stated the transition was smooth and there are no issues during and after the transition. The facility staff is working with R1's responsible party and R1's physicians to obtain the necessary required documents for R1's file. The facility staff is continuing to monitor and assess the resident to ensure the appropriate care and supervision is provided to R1. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator, Michael Rosete and a copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 8, 2024

Allegation investigated: Staff did not seek resident medical attention in a timely manner.

On 5/14/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit. LPA met with Co-Administrator (CAD) Michael Rosete and LPA explained the purpose of today's visit. Regarding the allegation of staff did not seek resident medical attention in a timely manner, reporting party (RP) stated that resident R1 has a fever of 101, with cough/congestion since Sun/Mon 1/16-17 and sending R1 to the hospital for evaluation and treatment. LPA visited the facility and interviewed CAD. CAD stated that there was no covid positive residents or staff in the facility during this time. There was an incident report submitted to Licensing that at 6:30 am on 1/18/22 R1 has non stop coughing, 911 was called immediately and R1 got transported the hospital. R1 was not tested in the facility for covid. Prior to 1/18/22, R1 didn’t have any symptoms nor was sick. Based on interviews and records review, the department has determined that that the allegation is false, could not have happened and/or is without a reasonable basis, therefore the allegations are UNFOUNDED. Report is reviewed and copy is provided. Unfoundedthe state’s words, verbatim · CDSS document, May 14, 2024 · control 26-AS-20220119152329