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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405802306
Report Date: 05/11/2022
Date Signed: 05/11/2022 04:59:44 PM


Document Has Been Signed on 05/11/2022 04:59 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 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:
05/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Jessica Bailey, AdministratorTIME COMPLETED:
05:19 PM
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On 5/11/22 at 4:00 pm, 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 the administrator and observed the following: The facility has infection control signage at the front door and signage throughout the facility on handwashing, cough etiquette and use of masks. Upon entry to the facility, LPA was screened. Staff are wearing masks. The facility has soap and hand sanitizing dispensers and paper towels in common bathrooms. The fire extinguishers (2) are located upstairs and downstairs next to the elevator doors. The extinguishers are fully charged and were inspected on 5/06/21. The administrator will ensure the extinguishers are inspected, take photos, and send to LPA by 5/18/22.

At 4:25 pm, LPA conducted the Infection Control mitigation module with the administrator. No deficiencies cited.

Exit interview conducted and report emailed to the administrator.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2022
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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