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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405802259
Report Date: 07/08/2022
Date Signed: 07/08/2022 01:26:07 PM


Document Has Been Signed on 07/08/2022 01:26 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:CHATEAU ROSEFACILITY NUMBER:
405802259
ADMINISTRATOR:SOO, ARPADFACILITY TYPE:
740
ADDRESS:1555 LAUREL LANETELEPHONE:
(805) 439-4774
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93401
CAPACITY:6CENSUS: 6DATE:
07/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Rachelle Tellez, Assistant AdministratorTIME COMPLETED:
01:40 PM
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On 7/08/22 at 12:05 pm, Licensing Program Analyst (LPA) Chavez conducted an unannounced annual infection control visit to the facility above. LPA met with Rachelle Tellez, Assistant Administrator, and explained the purpose of the visit.

LPA toured the facility with the assistant administrator and observed the following: The facility has infection control signage at the front door and signage throughout the facility on handwashing, cough etiquette and use of masks. Upon entry to the facility, LPA was screened. Staff are wearing masks. The facility has soap and hand saniter and towels in resident bathrooms. Each resident has their own bedroom and bathroom, and all resident rooms are located on the first floor. The fire extinguishers (2) are located downstairs next to the French doors and one in the entrance way closet. The extinguishers are fully charged and were inspected on 5/25/22. The facility has a pool with a fence around it with a locked gate. The facility has a water fountain in the backyard with no water in it.

At 12:46 pm, LPA conducted the Infection Control mitigation module with the assistant administrator. No deficiencies cited.

Exit interview conducted and report emailed to the licensee, general manager, and assistant administrator.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:
DATE: 07/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2022
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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