405802306-9-11-2024-29-AS-EMIR-D8ZVA3-20240911161517

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405802306
Report Date: 09/11/2024
Date Signed: 09/11/2024 04:15:37 PM

Document Has Been Signed on 09/11/2024 04:15 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	VISTA ROSA ELDER CARE		FACILITY NUMBER:	405802306
ADMINISTRATOR:	RACHELLE TELLEZ		FACILITY TYPE:	740
ADDRESS:	467 HILL STREET		TELEPHONE:	(805) 586-2200
CITY:	SAN LUIS OBISPO	STATE: CA	ZIP CODE:	93401
CAPACITY:	25	CENSUS:	DATE:	09/11/2024
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Jessia Bailey, Administrator		TIME COMPLETED:	04:30 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	Licensing Program Analyst (LPA) Miller arrived at 9:00 am to conduct a 1 year annual visit to the facility above. LPA met with Administrator, Jessica Bailey and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted. The following was inspected and noted during the annual visit: Infection Control: The facility has a current Infection Control Plan. The facility has a sign in and out binder for visitors at entry with hand sanitizer. The bathrooms have toilet paper, paper towels, hand soap, and hand washing signs are visible in the guest bathrooms. The facility has EPA approved disinfectant spray and cleaners. The facility has a 30-day supply of PPE. Quarantined or isolated individuals will have meals and medication delivered to rooms. Staff are trained on infection control and the use of Personal Protective Equipment (PPE). All trash cans and wastebaskets have tight fitting covers. Physical Plant & Environment Safety: The fire extinguisher was last charged and inspected on May 21, 2024. The facility has 19 resident bedrooms with ensuite bathrooms and 2 guest bathrooms. LPA was authorized to enter and inspect facility. The facility has smoke and carbon monoxide detectors that were last inspected on January 22, 2024 and a report was provided. The lighting and lamps are sufficient for the use of the facility and for resident comfort. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The showers have non-skid mats or textured bottoms. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant, cleaning solutions and poisons are inaccessible to residents in care land are locked in storage units. The facility has sufficient space inside and outside for activities and visiting. The facility has a patio for client use. The facility has telephone and internet service for resident use. Continued 809-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Erika Miller	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: VISTA ROSA ELDER CARE	FACILITY NUMBER: 405802306
	VISIT DATE: 09/11/2024

NARRATIVE

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Operational Requirements: The facility has a current plan of operation on file with the department. The Facility is operating in compliance with the granted fire clearance. The facility has current liability insurance and expires on April 29, 2025. The facility is approved for a capacity of 25. The fire clearance is granted for 25 non-Ambulatory, 25 of which may be bedridden. Hospice is approved for 8.

Staffing: The facility currently employes 14 full time staff, and 2 Administrators. Staff records are kept confidential. Files reviewed had current 1st Aid/CPR, Personnel Records/Application, Health screening with TB results, Criminal Record statements, and Fingerprint clearance and education requirements. It was determined that Staff 1 did not have a background clearance completed. Per the Guardian website, on December 26, 2022, and April 11, 2024, notices of Incomplete Fingerprint Submission Reminders were sent to Casa Rosa Elder Care email of record. The December 26, 2022, notice stated, “that the fingerprints required to complete your background check for CASA ROSA ELDER CARE - 405801779 have not yet been received. If you do not complete your fingerprints by 12/30/2022 your background check application request will be closed. An April 11, 2024, notice stated that if you do not complete your fingerprints by April 22, 2024, your background check application request will be closed. As a result, the agency will be notified that you have failed to complete this requirement.” As such, Staff 1 was not cleared and Staff 1 was required to leave the premises, until fingerprint clearance has been completed.Administrator disputes that the above correspondence was received by facility. Administrator noted that the facility received documentation that Staff 1 had a clearance with DOJ, but this document only indicates DOJ clearance was received and not the complete CCL clearance, which also reviews FBI records. Although, Staff 1 was associated to facility Staff 1 was not cleared to work and had a status of "in progess". Administrator Certificate is currently pending renewal.

Personnel Records & Training: The facility keeps confidential files for each staff member. Staff have annual training completed for various subjects/topics and hours for 2023 and 2024.

Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Facility does submit incident reports to the department when required. LPA reviewed 5 resident files for signed Admission Agreements, Safeguard for property and valuables, LIC. 602A Physicians report, Appraisals Needs and Services Plan, Emergency and ID forms.

Continued 809-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Erika Miller	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: VISTA ROSA ELDER CARE	FACILITY NUMBER: 405802306
	VISIT DATE: 09/11/2024

NARRATIVE

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Food Service: The facility handles and prepares food safely. The facility has 2-day perishables and 7-day non-perishables and plenty extra, to meet the food service requirement. The freezer is kept at 0 degrees and the refrigeration is kept at 40 degrees or lower. All food is covered, stored and marked appropriately. Cleaning solutions and equipment are stored separately from food supplies.

Incidental Medical Services: Facility provides assistance in arranging transportation to medical and dental appointments when needed. Residents have on-call doctor that visits facility. The facility uses the Medication Administration Record (MAR) along with the Centrally Stored Medication and Destruct Records (CSMDR). LPA reviewed residents’ medications, no labels were altered, no medications were expired and all medications were kept in their original containers.

Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts quarterly disaster drills. Emergency exits and telephone numbers were posted. Codes are available for staff on all shifts to access full facility in an emergency.

Residents with Special Health Needs: The facility does accept dementia residents in care. The facility currently has residents receiving Home Health services.

Exit interview conducted citation issued and copy of report and appeal rights printed for Administrator.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Erika Miller	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/11/2024 04:15 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VISTA ROSA ELDER CARE	FACILITY NUMBER: 405802306
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87355(e)(1)

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department.This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on on record review the licensee did not comply with the section when Staff 1 did not have criminal record clearance which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/12/2024
	Plan of Correction
1 2 3 4	Staff 1 was removed from her duties and Adminstrator agreed to have Staff 1 fingerprinted immediately.

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: Erika Miller	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024

LIC809 (FAS) - (06/04)

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