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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 03:48:47 PM


Document Has Been Signed on 05/11/2022 03:48 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:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:37 PM
MET WITH:Jessica Bailey, AdministratorTIME COMPLETED:
04:00 PM
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On 5/11/22 at 2:37 pm, Licensing Program Analyst (LPA) Darlene Chavez conducted an unannounced case management visit to the facility above. LPA met with Jessica Bailey, Administrator, and explained the reason for the visit.

On 5/11/22, Administrator faxed an incident report (LIC 624) and Report of Suspected Dependent Adult/Elder Abuse (SOC 341) to CCL stating that, on 5/10/22, Staff #1 (S1) witnessed Resident #1 (R1) being sexually abused by Staff #2 (S2) in R1’s room. Today, LPA interviewed the administrator and obtained documentation. Further investigation is needed.

Exit interview conducted and a copy of the 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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