405802284-9-26-2023-29-AS-DCHZ-CW2UVA-20230926155450

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405802284
Report Date: 09/26/2023
Date Signed: 09/26/2023 03:55:05 PM

Document Has Been Signed on 09/26/2023 03:55 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:	ROSES ASSISTED LIVING LLC		FACILITY NUMBER:	405802284
ADMINISTRATOR:	VICTORIA THORNE		FACILITY TYPE:	740
ADDRESS:	7270 VALLE AVE		TELEPHONE:	(805) 462-3302
CITY:	ATASCADERO	STATE: CA	ZIP CODE:	93422
CAPACITY:	6	CENSUS: 5	DATE:	09/26/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:37 AM
MET WITH:	Victoria Thorne, Administrator		TIME COMPLETED:	04:15 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 9/26/23 at 10:37 am, Licensing Program Analyst (LPA) Chavez made an unannounced Annual/Required visit to the facility listed above. LPA met with Staff #1 (S1) and explained the purpose of the visit. Approximately 30 minutes later, Victoria Thorne, Administrator, arrived. 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. Physical plant was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, and doors were checked, all in good condition. The facility maintains a comfortable temperature. The dual smoke detector and carbon monoxide detectors are hard-wired and were tested and operational. Fire extinguishers (2) located in the kitchen and double occupancy bedroom were inspected on 5/5/23 and are charged in the green. There are no issues with Fire Clearance. Living room and dining room furniture were checked and in good condition. The common rooms are clean, safe and sanitary. The courtyards of the facility have outdoor furniture with shaded areas for residents. The kitchen is 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. Garbage cans have tight fitting covers or are stored in cabinets. The kitchen's stove has knobs (5) attached and the kitchen is accessible to residents in care. Deficiency cited. The kitchen sink’s water temperature was measured at 118 F degrees. Resident rooms are adequately dressed with sheets, pillowcases, mattress pads, and blankets which are in good condition. There is at least one chair, nightstand and sufficient lighting for each resident. There is enough linen available to change regularly. Continued on 809-C.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

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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Document Has Been Signed on 09/26/2023 03:55 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 LLC	FACILITY NUMBER: 405802284
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87458(b)(1)

Medical Assessment

(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and interview, the licensee did not comply with the section cited above in that one out of five resident files reviewed indicate the resident does have a TB test which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/27/2023
	Plan of Correction
1 2 3 4	Licensee will provide TB results for the resident to CCL by the due date or provide documentation showing the test is in process.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/26/2023 03:55 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 LLC	FACILITY NUMBER: 405802284
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87463(a)

Reappraisals

(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and interview, the licensee did not comply with the section cited above in that two out of five resident files reviewed did not contain Appraisal, Needs, and Services Plans which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/03/2023
	Plan of Correction
1 2 3 4	Licensee has agreed to create Appraisal, Needs, & Service Plans to residents missing these documents and will send documents to CCL by the due date.

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and interview, the licensee did not comply with the section cited above in that quarterly disaster drills have not been completed which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/03/2023
	Plan of Correction
1 2 3 4	Licensee agrees to conduct an emergency disaster drill and send training sign-in shees to LPA by the due date.

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: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/26/2023 03:55 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 LLC	FACILITY NUMBER: 405802284
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(d)

Care of Persons with Dementia

(d) In addition to requirements specified in Section 87303, Maintenance and Operation, safety modifications shall include, but not be limited to, inaccessibility of ranges, heaters, wood stoves, inserts, and other heating devices to residents with dementia. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in that the kitchen stove had on/off handles and the kitchen is accessible to residents in care which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/03/2023
	Plan of Correction
1 2 3 4	Administrator immediately removed the handles and placed them in a locked drawer. Licensee will write a Statement of Understanding of the regulation cited and will send to CCL by the due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

LIC809 (FAS) - (06/04)

Page: 4 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 LLC	FACILITY NUMBER: 405802284
	VISIT DATE: 09/26/2023

NARRATIVE

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Storage closets have sufficient amounts of personal hygiene products which are provided by the licensee.
Bathrooms were checked for cleanliness and proper operation. The hot water temperature measured between 118.7 F and 120 F degrees in resident bathrooms.
Medications are centrally stored in a locked room in the garage. Medications are properly labeled and checked for expiration dates. A sampling of residents’ medications show they are centrally stored prescription and PRN medication which have been logged in the medications record with proper documentation from the residents’ doctors. Proper medication dispensing instructions are followed and checked for contamination. First Aid kit has all proper items and is current.
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. One out of five resident files reviewed did not contain TB results. Deficiency cited. Two out of five resident files reviewed did not contain Appraisal, Needs, and Services Plans. Deficiency cited. Planned activities are offered to residents in care.
Staff records were checked for expired or missing certificates, background clearances, and training: LPA conducted a file review of 5 staff for criminal record clearances/associations and current First Aid. All files are in-compliance.
Emergency disaster drills have not been conducted quarterly. The most recent drill was on 1/5/23. Deficiency cited.

Exit interview conducted, deficiencies cited, and the report and appeal rights given.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

LIC809 (FAS) - (06/04)

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