Citations (last 5 years)
Citations (over 5 years)
4.8 citations/year
Citations are regulatory findings recorded during state inspections.
20% worse than California average
California average: 4 citations/yearCitations per year
12
9
6
3
0
Occupancy
Latest occupancy rate
67% occupied
Based on a July 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Capacity: 6
Citations: 1
Date: Feb 3, 2026
Visit Reason
An unannounced Case Management visit was conducted to perform a facility closure tour and assess the facility's status.
Findings
The facility was observed to be non-operational with no residents present. The Administrator submitted the original license and was informed about the closure process. A Type B deficiency was cited for failure to notify the resident's responsible person as required by Health and Safety Code section 1569.683(b).
Citations (1)
Failure to notify or mail a copy of the notice to quit to the resident's responsible person as required by Health and Safety Code section 1569.683(b).
Report Facts
Capacity: 6
Census: 0
Plan of Correction Due Date: Feb 10, 2026
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tingxiu Li | Administrator | Met with Licensing Program Analyst during the visit and involved in closure process |
| Steve Chang | Licensing Program Analyst | Conducted the unannounced Case Management visit |
| Romeo Manzano | Licensing Program Manager | Named in the report as Licensing Program Manager |
| Chihhsien Chang | Licensing Program Analyst | Named in the report as Licensing Program Analyst |
Inspection Report
Annual Inspection
Census: 4
Capacity: 6
Citations: 1
Date: Jul 7, 2025
Visit Reason
An unannounced annual inspection visit was conducted by Licensing Program Analyst Steve Chang to evaluate compliance with licensing requirements at Rose Garden Elderly Care LLC.
Findings
The inspection found one deficiency related to inaccurate centrally stored medication forms for 2 residents, posing a potential health, safety, or personal rights risk. The facility otherwise met requirements for environment, safety equipment, and emergency preparedness.
Citations (1)
2 out of 2 residents' centrally stored medication forms were observed inaccurate with their medications, posing a potential health, safety or personal rights risk.
Report Facts
Deficiencies cited: 1
Beds with bed rails observed: 4
Staff observed: 2
Food supplies: 2
Food supplies: 7
Fire extinguisher service date: May 20, 2025
Emergency/fire drill date: Jun 1, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tingxiu Li | Administrator | Met with Licensing Program Analyst during inspection and involved in plan of correction |
| Steve Chang | Licensing Program Analyst | Conducted the unannounced annual inspection visit |
| Romeo Manzano | Licensing Program Manager | Named in report header and deficiency section |
| Chihhsien Chang | Licensing Program Analyst | Named in report header and deficiency section |
Inspection Report
Complaint Investigation
Census: 4
Capacity: 6
Citations: 0
Date: May 30, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 01/17/2025 that staff hit residents and spoke to residents in an inappropriate manner.
Complaint Details
The complaint alleged that staff hit residents and spoke to residents in an inappropriate manner. Interviews revealed no evidence of staff hitting residents; some residents reported a male staff yelling, but the facility has no male staff. The administrator and staff denied any abuse or yelling. The investigation concluded the allegations were unsubstantiated.
Findings
After interviews with residents, staff, and the administrator, and review of physician reports and facility records, the Department found the allegations unsubstantiated due to lack of preponderance of evidence. No citations were issued during the investigation.
Report Facts
Facility capacity: 6
Census: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Steve Chang | Licensing Program Analyst | Conducted the investigation visit and delivered findings |
| Chihhsien Chang | Licensing Evaluator | Conducted complaint investigation |
| Noemi Velasquez | Staff met with during investigation and exit interview | |
| Tingxiu Li | Administrator | Interviewed during investigation, denied allegations |
Inspection Report
Complaint Investigation
Census: 3
Capacity: 6
Citations: 0
Date: Jan 31, 2025
Visit Reason
An unannounced complaint investigation was conducted following a complaint alleging that staff left a resident soiled for an extended period of time.
Complaint Details
The complaint alleged that staff left a resident soiled for an extended period of time. Multiple interviews and observations were conducted. Some witnesses reported seeing the resident soiled on specific dates, but staff and other witnesses denied the allegation. The resident in question no longer lives at the facility. The allegation was unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation included interviews with staff, residents, and witnesses, as well as a facility tour. Although some witnesses reported seeing the resident in a soiled state, the Department found insufficient evidence to substantiate the allegation. The complaint was determined to be unsubstantiated.
Report Facts
Facility capacity: 6
Census: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Manuel Monter | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Tingxiu Li | Administrator | Facility administrator interviewed during investigation |
| Noemi Velasquez | Staff | Staff member met with during investigation and mentioned in findings |
Inspection Report
Complaint Investigation
Census: 1
Capacity: 6
Citations: 2
Date: Jan 17, 2025
Visit Reason
An unannounced complaint investigation was conducted due to violations discovered during the investigation process, focusing on case management deficiencies related to hospice care services notification and resident care planning.
Complaint Details
The visit was complaint-related, initiated by a complaint investigation. The deficiencies cited relate to failure to notify the Department about hospice care initiation and incomplete resident care planning. Substantiation status is not explicitly stated.
Findings
The facility failed to notify the Department in writing within five working days of the initiation of hospice care services for a resident and did not have a completed Appraisal/Needs and Services plan for the resident, posing potential health, safety, or personal rights risks.
Citations (2)
Failure to notify the Department of the initiation of hospice care services within five working days of admitting a resident already receiving hospice care services.
Resident's Needs and Services plan was not filled out, as the hospice nurse did not complete it.
Report Facts
Capacity: 6
Census: 1
Plan of Correction Due Date: Jan 24, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tingxiu Li | Administrator | Named in relation to findings about hospice care notification and resident care plan deficiencies |
| Manuel Monter | Licensing Program Analyst | Conducted complaint investigation and case management deficiencies visit |
| Marcela Yanez | Licensing Program Analyst | Conducted complaint investigation and case management deficiencies visit |
| Romeo Manzano | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 3
Capacity: 6
Citations: 1
Date: Dec 10, 2024
Visit Reason
An unannounced complaint investigation visit was conducted to deliver findings regarding allegations received about staff behavior towards residents.
Complaint Details
The complaint investigation was substantiated for the allegation that staff yelled at a resident but unsubstantiated for the allegation that staff hit a resident.
Findings
The allegation that staff yelled at a resident regarding non-payment of fees was substantiated and poses a potential health and safety risk. Another allegation that staff hit a resident was unsubstantiated due to lack of evidence.
Citations (1)
87468.1 Personal Rights of Residents in All Facilities - Residents shall be accorded dignity in their personal relationships with staff. This regulation has not been met as evidenced by staff yelling at a resident regarding non-payment of fees, posing an immediate health and safety risk.
Report Facts
Capacity: 6
Census: 3
Deficiencies cited: 1
Plan of Correction Due Date: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jaime Vado | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Noemi Velasquez | Staff | Met with during investigation and named in findings |
| Cara Smith | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Census: 3
Capacity: 6
Citations: 1
Date: Aug 16, 2024
Visit Reason
An unannounced case management - deficiencies visit was conducted to amend the annual required inspection that was conducted on July 31, 2024.
Findings
No deficiency was cited during the visit based on California Code of Regulations Title 22; however, a repeat violation was amended from the prior inspection. Chemicals accessible to residents were observed in multiple areas, posing an immediate health and safety risk.
Citations (1)
Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients were accessible to residents in the kitchen, bathroom, Sun Room and backyard.
Report Facts
Capacity: 6
Census: 3
Plan of Correction Due Date: Aug 17, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maria Partoza | Licensing Program Analyst | Conducted the inspection and cited deficiencies |
| TingXiu Li | Licensee/Administrator | Met with Licensing Program Analyst during inspection |
| Romeo Manzano | Licensing Program Manager | Supervisor of the inspection |
Inspection Report
Monitoring
Census: 3
Capacity: 6
Citations: 1
Date: Aug 8, 2024
Visit Reason
The visit was an unannounced case management health check to follow up on a resident admitted after the previous facility was closed due to a Temporary Suspension Order (TSO).
Findings
During the visit, a bar cart with over 6 bottles of alcohol was found accessible to residents with dementia, posing an immediate health and safety risk. The alcohol was removed and secured, and the administrator agreed to ensure alcohol remains inaccessible to residents with dementia.
Citations (1)
Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances must be stored inaccessible to residents with dementia; alcohol was accessible on a bar cart.
Report Facts
Number of alcohol bottles accessible: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Noemi Velasquez | Staff | Met with Licensing Program Analysts during inspection |
| Tingxiu Li | Licensee/Administrator | Spoke with Licensing Program Analysts and agreed to ensure alcohol is inaccessible to residents |
| Simranjit Rai | Licensing Evaluator | Conducted inspection and signed report |
| Steve Chang | Licensing Program Analyst | Arrived unannounced to conduct case management visit |
| Romeo Manzano | Supervisor | Supervisor overseeing inspection |
Inspection Report
Annual Inspection
Census: 2
Capacity: 6
Citations: 9
Date: Jul 31, 2024
Visit Reason
An unannounced required 1 year inspection visit was conducted to evaluate compliance with regulations for the Residential Care Facility for the Elderly.
Findings
Multiple deficiencies were cited related to medication labeling and records, storage of hazardous items accessible to residents, lack of PRN medication log, incomplete disaster drill documentation, and outdated medical assessments for residents. A civil penalty of $250 was assessed for a repeat violation.
Citations (9)
Chemicals accessible to residents in care in the kitchen, bathroom, Sun Room and backyard.
Medication container with pills was not labeled.
Steak knives in the kitchen lower drawer were not locked and accessible to residents.
Resident centrally stored medication logs did not list all medication bottles.
Facility did not maintain a PRN medication log as required.
Sun room lacks a sliding screen door; backyard screen door not attached.
Facility disaster drill log documentation was not maintained.
Residents with dementia did not have updated annual medical assessments.
Administrator did not conform to applicable laws and regulations, including lack of knowledge about PRN log and medication records.
Report Facts
Civil penalty amount: 250
Facility capacity: 6
Resident census: 2
Medications not listed in centrally stored medication log for Resident R1: 11
Medications not listed in centrally stored medication log for Resident R2: 9
Date of last fire extinguisher inspection: Jun 27, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tingxiu Li | Administrator/Licensee | Named in relation to findings and report review |
| Maria Partoza | Licensing Program Analyst | Conducted inspection and authored report |
| Manuel Monter | Licensing Program Analyst | Conducted inspection |
| Romeo Manzano | Licensing Program Manager | Supervisor of licensing evaluation |
Inspection Report
Census: 5
Capacity: 6
Citations: 0
Date: Jan 17, 2024
Visit Reason
The visit was an unannounced case management visit conducted by the Licensing Program Analyst to evaluate the facility and meet with the administrator.
Findings
No deficiencies were cited during the visit. The Licensing Program Analyst met with the administrator, who provided information about his recent start date and the care plans for residents.
Report Facts
Capacity: 6
Census: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Armando Guba | Administrator | Met with Licensing Program Analyst during the case management visit and provided information about facility operations |
| Manuel Monter | Licensing Program Analyst | Conducted the unannounced case management visit |
| Romeo Manzano | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 3
Capacity: 6
Citations: 0
Date: Oct 4, 2023
Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 06/19/2023 alleging staff were not meeting residents' dietary needs, not providing adequate food service, and leaving a resident in a soiled diaper for an extended period.
Complaint Details
The complaint alleged staff were not meeting residents' dietary needs, not providing adequate food service, and leaving a resident in a soiled diaper overnight. Interviews with residents, staff, and the administrator, as well as observations, did not provide sufficient evidence to substantiate these allegations. The complaint was determined to be unsubstantiated.
Findings
The investigation found sufficient food supply and accommodations for residents' dietary needs, with staff providing additional servings upon request. Residents and staff interviews indicated that toiletry needs were met regularly. However, one resident reported insufficient food variety and occasional delays in assistance. Overall, there was insufficient evidence to substantiate the allegations, and the complaint was unsubstantiated.
Report Facts
Facility capacity: 6
Resident census: 3
Complaint receipt date: Jun 19, 2023
Complaint control number: 26
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Manuel Monter | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Tingxiu Li | Administrator | Facility administrator interviewed regarding allegations |
Inspection Report
Annual Inspection
Census: 5
Capacity: 6
Citations: 8
Date: Aug 25, 2023
Visit Reason
The inspection was an unannounced annual facility inspection conducted to evaluate compliance with regulatory requirements for the Rose Garden Elderly Care LLC.
Findings
The inspection identified multiple deficiencies including unclean conditions such as full trash bins causing foul odors, improperly secured disinfectants and medications, excessively high hot water temperature, lack of CPR and first aid certification among staff, missing resident appraisal/needs and services plans, and incomplete medication storage records.
Citations (8)
Full trash bins causing foul odor, dirty refrigerator/freezer in garage, and dirty piles of wipes in backyard.
Hot water temperature maintained at 150 degrees Fahrenheit, exceeding safe limits.
Disinfectants, medications, and sharp objects not properly locked and secured.
Staff and administrator lack active CPR and first aid certification.
No appraisal/needs and services plan developed for 5 out of 5 residents.
No evacuation drill provided to staff as required quarterly.
Staff not trained on use of postural supports for residents using bed rails.
Centrally stored medications not kept in a safe and locked place accessible only to responsible employees.
Report Facts
Capacity: 6
Census: 5
Hot water temperature: 150
Residents without appraisal/needs plan: 5
Residents using half bed rails: 3
Residents using full length bed rails: 2
Staff without CPR and first aid certification: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tingxiu Li | Administrator | Facility administrator met during inspection and named in findings related to facility conditions and compliance |
| Christine Dolores | Licensing Program Analyst | Conducted the inspection and authored the report |
| Sarah Yip | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Original Licensing
Capacity: 6
Citations: 0
Date: Jul 6, 2022
Visit Reason
Licensing Program Analyst Ryker Heberle conducted an announced pre-licensing inspection of the facility to evaluate its readiness for licensure.
Findings
The facility was found to be in good repair with functioning smoke detectors, fire extinguisher, clean and furnished resident bedrooms, and safe bathrooms. The facility currently has no residents or staff aside from the licensee. Licensure is recommended pending creation of an emergency key set, obtaining liability insurance, and adjustment of water temperature to between 105°F and 120°F.
Report Facts
Water temperature measured: 96.1
Fire extinguisher purchase date: May 15, 2022
Food supply duration: 2
Food supply duration: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tingxiu Li | Administrator | Met with Licensing Program Analyst during pre-licensing inspection |
| Ryker Heberle | Licensing Program Analyst | Conducted the pre-licensing inspection |
Inspection Report
Original Licensing
Capacity: 6
Citations: 0
Date: Jun 29, 2022
Visit Reason
The visit was a pre-licensing inspection conducted via telephone call to evaluate the applicant's understanding of licensing requirements and facility operation.
Findings
The applicant and administrator successfully completed Component II of the licensing process, demonstrating understanding of Title 22 regulations, facility operation, staff qualifications, training, grievances, food service, medication management, and reporting processes.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ting Xiu Li | Administrator/Owner | Participated in COMP II and confirmed understanding of licensing requirements. |
| Shannon Betker | Analyst | CAB analyst who conducted the telephone call and confirmed applicant's understanding. |
| Darla Neeley | CAB manager | Participant in COMP II telephone call. |
| Jude De La Concepcion | Licensing Program Manager | Named in report header and signature section. |
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