Inspection Reports for
Rosegate

The facility failed to clear a previously issued deficiency related to auditory device requirements. A civil penalty of $200 was assessed for failure to correct the deficiency.

The complaint was substantiated. The resident eloped on 2025-08-19, was found by a bystander 3-4 blocks from the facility after falling, and was hospitalized with no noted injuries. The facility did not immediately notify the resident's responsible party, who learned of the incident before the facility called.

The investigation substantiated both allegations. The resident eloped from the facility, was found several blocks away with injuries requiring hospital transport, and the responsible party was not notified immediately by the facility. The facility failed to provide sufficient supervision and timely notification to the resident's representative.

The visit was conducted while Licensing Program Analysts were investigating complaint number 15-AS-20251027194916. The complaint was substantiated by observed deficiencies.

Two deficiencies were found: chemicals and disinfectants were left accessible to residents, and the facility failed to send incident reports to the licensing agency.

The visit was conducted as part of a complaint investigation (15-AS-20250430190433). The complaint involved concerns about resident space, medication safety, and documentation compliance. Some deficiencies were corrected during the visit.

The inspection found several deficiencies including limited space for Resident R1 to access the bathroom, lack of 'Oxygen in Use' signage in Resident R2's room, unlocked medication in a shared bedroom, and incomplete admission documentation for Resident R1.

The complaint was substantiated based on interviews with residents and staff, observations of the facility, and record reviews. The allegations included lack of a call system and insufficient bedroom furniture.

Both allegations were substantiated. The facility lacked a functioning call system for residents, with only a few residents having call pendants. Additionally, there were zero to one chair in each shared resident bedroom, and staff began bringing chairs during the visit.

The facility failed to report a COVID-19 outbreak involving nine positive residents to Local Public Health. Additionally, the facility did not have adequate bathroom accessibility for non-ambulatory residents, with only one bathroom available for 21 non-ambulatory residents.

Multiple deficiencies were observed including water temperature exceeding allowed limits, unlocked chemicals in storage, missing compliance posters, lack of oxygen storage signs, and outdated resident care plans and physician reports for residents with dementia.

The complaint was substantiated based on observations, interviews, and record reviews. The resident was found to be bedridden without the facility having the required fire clearance. The facility arranged for the resident's transfer to a skilled nursing facility.

The investigation found that resident R1 was bedridden but the facility was not cleared for bedridden residents. The allegation was substantiated and the facility arranged for R1 to be transferred to a skilled nursing facility.

The inspection found that staff and resident records were not stored at the facility, and one staff member was not associated with the facility. These deficiencies posed immediate health, safety, or personal rights risks to persons in care.

The complaint was substantiated based on the preponderance of evidence standard after observations, interviews, and record reviews.

The investigation found that an unlocked cleaning supply cart was stored in the backyard accessible to residents, posing an immediate health and safety risk. The allegations were substantiated based on observations and interviews.

This visit was triggered by a priority 1 complaint. The deficiency related to fingerprint clearance was substantiated and resulted in a civil penalty.

The licensee was found to have staff working without obtaining required fingerprint clearances, violating Title 22 California Code of Regulations. A civil penalty of $500 was assessed.

The complaint investigation was substantiated based on evidence that staff training documentation was missing and the facility exceeded its hospice waiver limit. The allegations were confirmed by Licensing Program Analyst Daisy Panlilio during the investigation.

The investigation substantiated that facility staff were not properly trained as documentation for 2019 training was not produced. Additionally, the facility was found to have more residents on hospice care than allowed by the hospice waiver at the time of inspection.