405802299-2-14-2023-29-AS-DCHZ-CP2TP9-20230214135357

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405802299
Report Date: 02/14/2023
Date Signed: 02/14/2023 01:56:05 PM

Document Has Been Signed on 02/14/2023 01:56 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 CARE		FACILITY NUMBER:	405802299
ADMINISTRATOR:	BAILEY, JESSICA		FACILITY TYPE:	740
ADDRESS:	461 HILL STREET		TELEPHONE:	(805) 586-3438
CITY:	SAN LUIS OBISPO	STATE: CA	ZIP CODE:	93401
CAPACITY:	6	CENSUS: 5	DATE:	02/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:37 AM
MET WITH:	Jessica Bailey, Administrator		TIME COMPLETED:	02:10 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 2/14/23 at 11:37 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. Screening and visitor sign-in was available at the entryway. Each resident room is single-occupancy and includes an attached bathroom. Bathrooms are stocked with soap and paper towels. The facility has signage for COVID infection control measures. The facility currently has two residents in COVID isolation and signage indicating this is posted on their bedroom doors. A fire extinguisher located in the hall next to the kitchen was is fully charged and was inspected on 5/17/22. At 11:50 am, LPA observed more than ten containers of cleaning supplies in an unlocked laundry room. Administrator states that at this time, there are currently no residents diagnosed with dementia, however, the facility is licensed for dementia residents and there must be in compliant Care of Persons with Dementia. Deficiency cited. At 1:01 pm, LPA conducted the Infection Control mitigation module with the administrator.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2023

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 02/14/2023 01:56 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: VISTA ROSITA ELDER CARE	FACILITY NUMBER: 405802299
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(2)

87705(f)(2) Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: 2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	.Based on observation, the licensee did not comply with the section cited above as more than ten containers of cleaning supplies were observed in an unlocked laundry room which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/15/2023
	Plan of Correction
1 2 3 4	The administrator immediately removed all cleaning supplies and placed them in a locked closet. Administrator has requested that the maintenance director place a numbered keypad/lock on the laundry room door immediately, and administrator will send a photo of the lock to CCL by 2/15/23. Licensee agrees to provide training to staff about ensuring all toxic substances are inaccessible to residents and send the training sign-in sheet to CCLD by 2/15/23.

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: 02/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2023

LIC809 (FAS) - (06/04)

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