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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405802299
Report Date: 03/02/2022
Date Signed: 03/02/2022 04:11:41 PM


Document Has Been Signed on 03/02/2022 04:11 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:VISTA ROSITA ELDER CAREFACILITY NUMBER:
405802299
ADMINISTRATOR:BAILEY, JESSICAFACILITY TYPE:
740
ADDRESS:461 HILL STREETTELEPHONE:
(805) 586-3438
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93401
CAPACITY:6CENSUS: 5DATE:
03/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Jessica Bailey, AdministratorTIME COMPLETED:
12:26 PM
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On 3/02/22 at 10:50 am, Licensing Program Analyst (LPA) Chavez conducted an unannounced on-site annual infection control visit to the facility above. LPA met with Administrator Jessica Bailey and explained the purpose of the visit.

LPA toured the facility with administrator and observed the following: The facility has signage at the front door regarding the visitor policy. LPA was screened upon entry. Each resident room is single-occupancy and includes an attached bathroom. Individual resident bathrooms and the bathroom in the common area were stocked with soap and paper towels. The facility has signage for COVID infection control measures including cough etiquette and handwashing reminders. A fire extinguisher, located in the hall adjacent to the common area bathroom, is fully charged and was inspected on 5/06/2021. LPA observed two staff with surgical masks which were slightly falling below their noses. LPA inquired with one of the staff who stated that the mask is a bit large. Administrator will assess staff masks, conduct training on proper donning and doffing of PPE, and send LPA the sign-in sheet for staff training of proper mask use.

At 11:35 am, LPA conducted the Infection Control mitigation module with the administrator. No deficiencies cited.

Exit interview conducted and report emailed to the administrator.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:
DATE: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2022
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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