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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405802306
Report Date: 12/29/2021
Date Signed: 12/29/2021 04:47:13 PM

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: 21DATE:
12/29/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Zoltan SooTIME COMPLETED:
02:30 PM
NARRATIVE
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On 12/29/21 at 11:00 am, Licensing Program Analysts (LPAs) Darlene Chavez and Jenny Olson conducted a 10-day complaint investigation. During the investigation at 12:55 pm, LPAs observed that Resident #1 (R1) and Resident #2 (R2) have bed rails extending the full length on both sides of their common queen-sized bed. All four bed rails were in the upright position, each side of the bed having a top half rail and a bottom half rail. Resident #2 was asleep or resting in the bed at the time LPAs visited. Staff #1 (S1) stated that neither R1 nor R2 are on hospice. S1 provided documentation from R1 and R2 physician showing they are approved for half bed rails. LPA Chavez questioned staff as to why R1 and R2 had full bed rails, and S1 and Administrator stated they did not know, but that R1 and R2 fall “frequently.” LPA Chavez communicated to S1 and Administrator that full bed rails are not permitted and instructed them to immediately remove the bottom half rails on both sides of the bed immediately which S1 and Administrator did. Photos were taken.

The following deficiency was observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiency may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were emailed.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2021
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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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 ROSA ELDER CARE
FACILITY NUMBER: 405802306
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/29/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/29/2021
Section Cited

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87608(a)(5)(B): Postural Supports. 87608(a)(5)(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

The requirement is not met as evidence by:
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Based upon observation and interview, the licensee did not obtain hospice orders for full bed rails on R1’s and R2’s bed, which poses a potential health and safety risk to residents in care.
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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 BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:
DATE: 12/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/29/2021
LIC809 (FAS) - (06/04)
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