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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019201382
Report Date: 05/08/2026
Date Signed: 05/08/2026 04:50:14 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/22/2025 and conducted by Evaluator Yasamin Brown
COMPLAINT CONTROL NUMBER: 15-AS-20251222141547
FACILITY NAME:ROSEMONT GARDENSFACILITY NUMBER:
019201382
ADMINISTRATOR:LEUNG, BELINDAFACILITY TYPE:
740
ADDRESS:1345 CLARKE STREETTELEPHONE:
(510) 483-0150
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY:45CENSUS: 39DATE:
05/08/2026
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Roselyn Chand, AdministratorTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Facility staff did not seek medical attention for residents with scabies.
Facility staff did not adequately supervise resident who is a fall risk, resulting in resident falling multiple times.
Facility staff did not provide assistance to resident in a timely manner.
Facility staff did not inform resident's responsible party of incidents.
INVESTIGATION FINDINGS:
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13
On 5/8/2026 at 9:30 AM, Licensing Program Analyst (LPA) Y. Brown arrived unannounced to conduct a complaint investigation and deliver findings in regards to the allegation above. LPA met with Roselyn Chand, Administrator and explained the purpose of the visit.

During the investigation, LPA interviewed 5 staff members and 7 residents. LPA obtained and reviewed the facilities LIC500 (Personnel Record) and Resident Roster. LPA obtained and reviewed the following resident documents: Care Plans, Emergency Information and Contact, LIC602 (Physician's report), Appraisal Needs and Services Plan, body check assessments, Shower skin check log, Inventory checklist (Months of September-December), Skin Treatment Log, and Progress notes.

Continue on LIC9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Yasamin Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2026
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 7
Control Number 15-AS-20251222141547
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ROSEMONT GARDENS
FACILITY NUMBER: 019201382
VISIT DATE: 05/08/2026
NARRATIVE
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Allegation: Facility staff did not seek medical attention for residents with scabies.
Finding: Substantiated

It was alleged that facility staff did not seek medical attention for residents with scabies. Interview with staff revealed that R1 had an ongoing rash in October 2025 but they were not sure exactly for how long. During record review, LPA requested daily progress notes of R1 in October 2025 but none of the notes identified the rash that staff noticed. S1, S2 and W1 stated that W1 came to visit R1 on 10/20/2025 and 10/21/2025 and noticed a cut on R1’s forearm and noticed R1 itching their body. W1 took R1 to the doctor for the cut and as R1 was at the hospital, the doctor also noticed that R1 had a rash. W1, S1 and S2 stated that R1 returned to the facility on 10/21/2025 and the doctor diagnosed R1 with scabies. S1, S2, S3, S4 and S5 stated that they remember R1 having a rash but they did not know it was scabies until R1 came back from the hospital with W1. LPA observed that the facility did not seek medical attention for R1’s scabies although they had identified R1 having an ongoing rash and itching their body.


Allegation: Facility staff did not adequately supervise resident who is a fall risk, resulting in resident falling multiple times.
Finding: Substantiated

It was alleged that facility staff did not adequately supervise resident who is a fall risk, resulting in resident falling multiple times. Interviews with staff revealed that they were aware that R1 was a fall risk. Interviews with staff revealed that R1 would fall and sustain multiple unwitnessed falls. Staff were not able to identify the exact times but stated that they have found R1 on the floor from falling. During record review, LPA could not identify a fall risk plan/procedure implemented for R1. Although facility staff were aware of R1's multiple falls, they failed to take adequate measures to ensure R1’s safety, resulting in multiple falls and/or being found on the floor in R1's room.


Continue on LIC9099-C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Yasamin Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/22/2025 and conducted by Evaluator Yasamin Brown
COMPLAINT CONTROL NUMBER: 15-AS-20251222141547

FACILITY NAME:ROSEMONT GARDENSFACILITY NUMBER:
019201382
ADMINISTRATOR:LEUNG, BELINDAFACILITY TYPE:
740
ADDRESS:1345 CLARKE STREETTELEPHONE:
(510) 483-0150
CITY:SAN LEANDROSTATE:CAZIP CODE:
94577
CAPACITY:45CENSUS: 39DATE:
05/08/2026
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Roselyn Chand, AdministratorTIME COMPLETED:
05:30 PM
ALLEGATION(S):
1
2
3
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9
Facility staff did not administer prescribed medication to a resident in care.
Facility staff did not safeguard residents belongings.
INVESTIGATION FINDINGS:
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13
On 5/8/2026 at 9:30 AM, Licensing Program Analyst (LPA) Y. Brown arrived unannounced to conduct a complaint investigation and deliver findings in regards to the allegation above. LPA met with Roselyn Chand, Administrator and explained the purpose of the visit.

During the investigation, LPA interviewed 5 staff members. LPA obtained and reviewed the facilities LIC500 (Personnel Record) and Resident Roster. LPA obtained and reviewed the following resident documents: Care Plans, Emergency Information and Contact, LIC602 (Physician's report), Appraisal Needs and Services Plan, body check assessments, Shower skin check log, Inventory checklist (Months of September-December), Skin Treatment Log, and Progress notes.

Continue on LIC9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Yasamin Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 15-AS-20251222141547
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ROSEMONT GARDENS
FACILITY NUMBER: 019201382
VISIT DATE: 05/08/2026
NARRATIVE
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***This is an amended report from visit on 5/8/2026***

Continued from LIC9099.

Allegation: Facility staff did not administer prescribed medication to a resident in care.
Finding: Unsubstantiated

It was alleged that facility staff did not administer prescribed medication to residents in care; however, based on the investigation, including interviews and record reviews, there was insufficient evidence to support the allegation. S4 stated that they administer prescribed medication to residents in care. Medication administration records and staff documentation were consistent with prescribed orders, and no discrepancies were observed during the review. Staff demonstrated appropriate medication handling and administration procedures in accordance with facility policy and regulatory requirements.


Allegation: Facility staff did not safeguard residents belongings
Finding: Unsubstantiated

It was alleged that the facility staff did not safeguard resident belongings; however, based on the investigation, including interviews and record reviews, there was insufficient evidence to support the allegation. Interviews with staff and RP revealed that W1 is responsible for R1’s laundry. Interviews with staff revealed that the facility has misplaced R1’s dress in the past but it was found in R1’s room and returned to R1 the same day but no additional incidents have occurred. Interviews with residents revealed that they have never experienced any of their personal items missing.


Based on interviews, observations conducted and record review, the above allegations are unsubstantiated. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

No deficiency cited. Exit Interview conducted with Roselyn and copy of this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Yasamin Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 15-AS-20251222141547
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ROSEMONT GARDENS
FACILITY NUMBER: 019201382
VISIT DATE: 05/08/2026
NARRATIVE
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Allegation: Facility staff did not provide assistance to resident in a timely manner.
Finding: Substantiated

It was alleged that facility staff did not provide assistance to resident in a timely manner. Interview with staff revealed that R1 had an ongoing rash and was consistently itching their body but the rash was not addressed with R1’s doctor. R1’s rash was diagnosed by the doctor as scabies after W1 took R1 to the hospital for a different matter. Although staff were aware of the rash, the facility did not address R1’s rash in a timely manner.

Allegation: Facility staff did not inform resident's responsible party of incidents.
Finding: Substantiated

It was alleged that the facility staff did not inform resident’s responsible party of incidents. RP stated that they were not made aware of R1’s ongoing rash. RP stated that they discovered that R1 fell two times on 11/3/2025 and the staff did not notify R1’s responsible party of the incidents. Interview with staff revealed that they did not notify R1's responsible party about R1 falling. S1 and S2 stated that they did not notify R1’s responsible parties about the multiple incidents regarding R1.

Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D.



Exit Interview conducted with Roselyn, appeal rights and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Yasamin Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 15-AS-20251222141547
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ROSEMONT GARDENS
FACILITY NUMBER: 019201382
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/08/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/22/2026
Section Cited
CCR
87465(a)
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(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
This requirement is not met as evidenced by:

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By POC date, the administrator agrees to conduct an in-service training regarding regulation 87465 with all staff. Administrator agrees to send proof of the in-service to CCLD.
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Based on record review and interviews, the licensee did not compy with the section above by not seeking immediate medical attention for R1 who had scabies which posed an immediate health and safety risks to person in care.
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Type B
05/22/2026
Section Cited
CCR
87468.2(a)(4)
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(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents...shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs...
This requirement is not met as evidenced by:

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By POC date, the Administrator agrees to review all residents that are a fall risk and implement a fall prevention plan for those residents. The Administrator agrees to also conduct an in-service regarding the plans with all staff and send proof of the in-service to CCLD.
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Based on record review and interviews, the licensee did not comply with the section above by staff acknowledging that R1 was a fall risk but facility staff failing to provide adequate supervision which posed a potential health and safety risks to person 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.
SUPERVISOR'S NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Yasamin Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 15-AS-20251222141547
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ROSEMONT GARDENS
FACILITY NUMBER: 019201382
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/08/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/22/2026
Section Cited
CCR
87211(a)(1)
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(a) Each licensee shall furnish to the licensing agency such reports..(1) A written report shall be submitted.. to the person responsible for the resident...

This requirement is not met as evidenced by:
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By POC due date, the Administrator agrees to conduct an in-service retraining on regulation 87211(a) and send proof of the in-service to CCLD.
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Based on record review and interview, the licensee did not comply with the section cited above in that the facility did not inform R1's responsible party of incidents regarding R1 at the facility which poses a potential safety risk to persons in care.
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Type B
05/15/2026
Section Cited
CCR
87411(a)
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(a) Facility personnel shall at all times be sufficient in numbers, and competent... In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care...
This requirement is not met as evidenced by:
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By POC due date, the Administrator agrees to conduct an in-service retraining on regulation 87411 and send proof of the in-service to CCLD.
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Based on record review and interview, the licensee did not comply with the section cited above in that the facility did not provide assistance to R1 in a timely manner which poses a potential safety 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.
SUPERVISOR'S NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Yasamin Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2026
LIC9099 (FAS) - (06/04)
Page: 7 of 7