405802259-7-23-2024-29-AS-MRAN-D7FTDZ-20240723143911

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405802259
Report Date: 07/23/2024
Date Signed: 07/23/2024 02:39:26 PM

Document Has Been Signed on 07/23/2024 02:39 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:	CHATEAU ROSE		FACILITY NUMBER:	405802259
ADMINISTRATOR:	GERMAIN, ANDRIANNA		FACILITY TYPE:	740
ADDRESS:	1555 LAUREL LANE		TELEPHONE:	(805) 439-4774
CITY:	SAN LUIS OBISPO	STATE: CA	ZIP CODE:	93401
CAPACITY:	6	CENSUS: 5	DATE:	07/23/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Andrianna Germain, Rachelle Tellez, Administrators		TIME COMPLETED:	02:45 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	On 7/23/24 at 09:15 am, Licensing Program Analyst (LPA) Rankin made an unannounced Annual/Required visit to the facility listed above. LPA met with Andrianna Germain, Administrator, and Rachelle Tellez, Administrator, and explained the purpose of the visit. A tour of the physical plant was assessed, and the following was noted: LPA observed the license posted, Complaint Poster, Bill of Rights and Right to Residential Council, non-discrimination statement, and resident rights in the front entry and hall near kitchen. Emergency Disaster Preparedness plan is current, and forms were posted. The facility provides disaster drills quarterly. The fire extinguishers were charged and reviewed in May of 2024. Fire extinguishers are located in the kitchen and the hallway near room #3. The dual smoke and carbon monoxide detectors are present and hard wired throughout the facility and were tested and were in working order. Physical plant was checked for cleanliness and condition. Walls, windows, ceilings, floors, floor coverings, and doors were checked, all in good condition. The facility maintains a comfortable temperature. The facility has 6 bedrooms and 6 resident bathrooms currently occupying 5 residents. Living room and dining room area have sufficient space for activities and visiting. The furniture was checked and is in good condition. The common rooms are clean, safe, and sanitary. Continued on 809-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Melisa Rankin	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024

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: CHATEAU ROSE	FACILITY NUMBER: 405802259
	VISIT DATE: 07/23/2024

NARRATIVE

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Outdoors area of the facility has outdoor furniture with shade for residents and visitors. There are gardens and walkable paths. There is a jacuzzi with a hard top secured and locked and a fenced in pool, both are inaccessible to residents.

The kitchen and pantry were sufficiently stocked with two-day perishable and seven-day non-perishables. Foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Emergency supply of food and water is available. Garbage cans have tight fitting covers. Refrigerator is kept at 40 F or below and the freezer at 0 F degrees. The kitchen chemicals are locked under the sink.

Resident rooms are adequately dressed with sheets, pillowcase, mattress pad, and blankets which are in good condition. There is at least one chair, night stand, and sufficient lighting for each resident. There is enough linen available to change weekly or more, if needed.

Storage cabinets have enough personal hygiene product which is provided by the licensee and all cleaning products, toxins are stored and locked away inaccessible to residents in care.

Bathrooms were checked for cleanliness, secured grab bars and proper operation. All clients have their personal restroom, and they were all found clean, with proper hand washing notices, soaps, and paper towels.

Medications are centrally stored in the locked room upstairs, and double secured in a locked medicine cabinet. Medications are properly labeled and checked for expiration dates. A sampling of resident’s medication show they are recorded properly with the Centrally Stored Medication and Destruct Records (CSMDR), they are all were up to date, legible and written as prescribed.

Continued on 809-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Melisa Rankin	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024

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: CHATEAU ROSE	FACILITY NUMBER: 405802259
	VISIT DATE: 07/23/2024

NARRATIVE

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Residents with Special Health Needs: The facility does accept dementia residents in care. All items that could pose a danger such as sharps, and cleaners were locked separately in cupboards. The facility has a license for 6 Non-Ambulatory which 1 may be bedridden in room 3. The facility does not have delayed egress. The facility does have hospice and home health visits to the facility for residents in care.

Operational Requirements: The Facility is operating in compliance with the fire clearance. The facility provided current up to date liability insurance. All Dementia requirements are being met. Hospice wavier granted for 3.

Resident records were reviewed for requirements and legibility: LPA reviewed 5 residents’ files for Medical Assessments, Needs and Service plans, Signed Admission Agreements and Pre-appraisals. There were no issues with resident files reviewed.

Staff records were checked for expired or missing certificates and clearances: LPA conducted a file review of 5 staff for criminal record clearances/associations/and current First Aid. All required training has been completed. There were no issues with staff files.

Exit interview conducted and report given.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Melisa Rankin	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024

LIC809 (FAS) - (06/04)

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