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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405802284
Report Date: 09/29/2021
Date Signed: 09/29/2021 04:10:31 PM

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:ROSES ASSISTED LIVING LLCFACILITY NUMBER:
405802284
ADMINISTRATOR:VICTORIA THORNEFACILITY TYPE:
740
ADDRESS:7270 VALLE AVETELEPHONE:
(805) 462-3302
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY:6CENSUS: 6DATE:
09/29/2021
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
09:18 AM
MET WITH:Victoria Thorne, AdministratorTIME COMPLETED:
11:30 AM
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On 9/29/21 at 9:18 am, Licensing Program Analyst (LPA) Darlene Chavez arrived at the facility to meet with Administrator Victoria Thorne for a technical support visit with this facility. Staff informed LPA Ms. Thorne was not at the facility and called Ms. Thorne who arrived at 10:05 am. In attendance included Public Health Infection Preventionist Jeannette Tosh from San Luis Obispo County Public Health. The purpose of the visit had a specific emphasis on infection control practices.

Upon entry into the facility, LPA found no signage on or near the front door cautioning visitors that COVID-19 was in the facility. The facility has a central entry point for signing in, symptom screening, and temperature checks. The facility has appropriate signs in the common spaces to promote proper hand hygiene, physical distancing, and symptom reporting. Staff were observed wearing N95 masks, gowns, gloves and goggles. Hand sanitizer was available throughout the common spaces for resident and staff use.

During today's visit, discussion took place regarding the current status of positive residents and staff, testing, communication to staff and families, symptom screening, signage, and procedures around visitation. The facility is not experiencing any issues with staffing. Facility was in need of gloves, gowns, and face shields. LPA brought 100 gowns, two cases of gloves, and five face shields for the facility. Cleaning and disinfectant protocol is adequate.

No health and safety hazards noted during today's visit. Exit interview conducted. A copy of the report was emailed to te administrator.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021
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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