405802306-8-9-2021-29-AS-KBUY-C5QREP-20210809125751

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405802306
Report Date: 08/09/2021
Date Signed: 08/09/2021 12:41:26 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/11/2019 and conducted by Evaluator Rachael De Leon

COMPLAINT CONTROL NUMBER: 29-AS-20191211111130

FACILITY NAME:	VISTA ROSA ELDER CARE		FACILITY NUMBER:	405802306
ADMINISTRATOR:	BAILEY, JESSICA		FACILITY TYPE:	740
ADDRESS:	467 HILL STREET		TELEPHONE:	(805) 235-0286
CITY:	SAN LUIS OBISPO	STATE: CA	ZIP CODE:	93401
CAPACITY:	25	CENSUS: 18	DATE:	08/09/2021
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Jessica Bailey, Administrator		TIME COMPLETED:	12:50 PM

ALLEGATION(S):

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Staff member denies residents beverage of choice
Facility isolates resident to their bedroom
Staff are not trained properly or adequately with resident’s assistance with daily living

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to the facility above to deliver final findings of the complaint allegations. LPA met with Jessica Bailey and explained the purpose of the visit.

During the investigation, LPA conducted interviews with staff on 12/16/2019 around 8:31 AM, 3:45 PM, 4:11 PM, on 08/05/2021 at 12:34 PM and 12:51 PM and on 08/06/2021 at 1:11 PM. LPA conducted interviews with witnesses on 08/05/2021 at 1:14 PM, 1:42 PM, 1:44 PM, 1:58 PM, and on 08/06/2021 at 10:25 AM. LPA reviewed documentation on 12/16/2019 around 3:30 PM, on 08/04/2021 at 1:30 PM, 4:45 PM, on 08/06/2021 around 10:00 AM and on 08/09/2021 at 11:45 AM.

Continued 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20191211111130

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 ROSA ELDER CARE	FACILITY NUMBER: 405802306
	VISIT DATE: 08/09/2021

NARRATIVE

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On the allegation: Staff member denies residents beverage of choice. LPA interviewed Staff 1 (S1), Staff 2 (S2), Staff 4 (S4), Staff 5 (S5) and staff 6 (S6) as well as interviewed witness 1 (W1), Witness 2 (W2), witness 3 (W3), Witness 4 (W4), Witness 5 (W5) and Witness 6 (W6) none of the interviews conducted revealed staff member denying residents choice of beverage. Based on the lack of evidence this allegation is deemed Unsubstantiated at this time.

On the allegation: Facility isolates resident to their bedroom. LPA interviewed S1, S2, S4, S5, S6, W1, W2, W3, W4, W5 and W6 none of the interviews revealed residents were being isolated. W1-W5 interviews revealed residents were free to do what they wanted, and staff encouraged activities and socialization with the residents. Based on lack of evidence this allegation is deemed Unsubstantiated at this time.

On the allegation: Staff are not trained properly or adequately with resident’s assistance with daily living. LPA interviews with S1, S2, S4, S5, S6 revealed that staff are trained properly and adequately to handle the residents care and assistance with daily living. Interviews with W1-W6 revealed the staff seemed to be trained and staff know how to take care of the residents properly. LPA reviewed training records of staff on 08/09/2021 at 11:45 am which show staff were trained according to regulation requirements. Based on the lack of evidence this allegation is deemed Unsubstantiated at this time.

Exit interview conducted and copy of report emailed to the administrator.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2021

LIC9099 (FAS) - (06/04)

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