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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405802306
Report Date: 05/26/2021
Date Signed: 05/26/2021 10:56:28 AM

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 ROSA ELDER CAREFACILITY NUMBER:
405802306
ADMINISTRATOR:BAILEY, JESSICAFACILITY TYPE:
740
ADDRESS:467 HILL STREETTELEPHONE:
(805) 586-2200
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93401
CAPACITY:25CENSUS: 19DATE:
05/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:11 AM
MET WITH:Jessica Bailey, AdministratorTIME COMPLETED:
11:05 AM
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At 9:11am, on 05/26/2021, Licensing Program Analysts (LPAs) Darlene Chavez and Arien Diaz conducted an unannounced annual infection control inspection of the facility above. LPAs informed administrator of the reason for the visit. LPAs and administrator toured the facility. LPAs' initial tour of the facility resulted in observations which were immediately addressed by the administrator and facility staff: At 9:18 am, a hand towel was added to resident room #18 bathroom. At 9::50 am, door to roof access room was fully shut and locked.

At 10:10 am, LPA Chavez conducted Infection Control mitigation module with administrator. No deficiencies.

Exit interview conducted and report given to administrator.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Arien DiazTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2021
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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