405801779-1-29-2024-29-AS-EMIR-CZXUCB-20240129142741

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405801779
Report Date: 01/29/2024
Date Signed: 01/29/2024 02:28:53 PM

Document Has Been Signed on 01/29/2024 02:28 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	CASA ROSA ELDER CARE		FACILITY NUMBER:	405801779
ADMINISTRATOR:	RACHELLE TELLEZ		FACILITY TYPE:	740
ADDRESS:	2172 S. HALCYON ROAD		TELEPHONE:	(805) 473-0306
CITY:	ARROYO GRANDE	STATE: CA	ZIP CODE:	93420
CAPACITY:	22	CENSUS: 13	DATE:	01/29/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Rachelle Tellez, Administrator		TIME COMPLETED:	02:40 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Erika Miller arrived at 9:35 am to conduct a 1 year annual visit to the facility above. LPA met with Administrator Rachelle Tellez and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted. The following was inspected and noted during the annual visit: Infection Control: The facility has a current Infection Control Plan. The facility has a sign in and out binder for visitors at entry with hand sanitizer. The bathrooms have toilet paper, paper towels, hand soap, and hand washing signs. Quarantined or isolated individuals will have meals and medication delivered to rooms. Staff are trained on infection control and the use of Personal Protective Equipment (PPE). All trash cans and wastebaskets have tight fitting covers. Physical Plant & Environment Safety: The fire extinguishers were last charged and inspected on May 3, 2023. The facility is a 17 resident bedrooms currently occupying 13 residents and employs 18 full time staff and three Administrators. LPA was authorized to enter and inspect facility. The facility has smoke and carbon monoxide detectors. The lighting and lamps are sufficient for the use of the facility and for resident comfort. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The showers have non-skid mats. The pathways are clear of any obstructions. Facility is well lit inside and outside. Disinfectant, cleaning solutions and poisons are inaccessible to residents in care and locked in cupboards and closets. The facility has sufficient space inside and outside for activities and visiting. The facility has plenty of shade. The facility has telephone and internet service for resident use. Continued 809-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Erika Miller	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CASA ROSA ELDER CARE	FACILITY NUMBER: 405801779
	VISIT DATE: 01/29/2024

NARRATIVE

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Operational Requirements: The facility has a current plan of operation on file with the department. The Facility is operating in compliance with the granted fire clearance. The facility has current liability insurance and expires on April 29, 2024. The facility is approved for a capacity of 22. The fire clearance is granted for 22 Non-Ambulatory of which 18 may be bedridden and Hospice is approved for 8.

Staffing: The facility currently employes 18 full time staff and 3 Administrators. Staff records are kept confidential. Files reviewed had current 1st Aid/CPR, Personnel Records/Application, Health screening with TB results, and Criminal Record statements. Administrator Certificates expires May 10, 2024.

Personnel Records & Training: The facility keeps confidential files for each staff member. Staff have annual training completed for all subjects/topics and hours for 2023.

Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Facility does submit incident reports to the department when required. LPA reviewed 5 resident files for signed Admission Agreements, Personal Rights, Safeguard for property and valuables, Physician’s reports Pre-appraisals, Appraisals Needs and Services Plan, Emergency and ID forms, all forms were legible and records are kept confidential.

Food Service: The facility handles and prepares food safely. The facility has 2 day perishables and 7 day non-perishables to meet the food service requirement. The freezer is kept at 0 degrees and the refrigeration is kept at 40 degrees or lower. All food is covered, stored and marked appropriately. Cleaning solutions and equipment are stored separately from food supplies.

Residents with Special Health Needs: The facility does accept dementia residents in care. Facility currently has one resident on oxygen . The facility currently has 4 hospice residents in care. The facility currently has residents receiving Home Health services. The facility does not have delayed egress, but is a gated community.

Exit interview conducted and copy of report printed for Administrator.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Erika Miller	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024

LIC809 (FAS) - (06/04)

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