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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405802306
Report Date: 07/20/2022
Date Signed: 07/20/2022 12:31:22 PM


Document Has Been Signed on 07/20/2022 12:31 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:
07/20/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Rachelle Tellez, Assistant Administrator, and Leah Figaro, Human Resources ManagerTIME COMPLETED:
01:38 PM
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On 7/20/22 at 11:55 am, Licensing Program Analyst (LPA) Darlene Chavez conducted a Case Management - Incident visit to issue final findings and citations related to the Case Management visit conducted on 05/11/2022. LPA met with Rachelle Tellez, Assistant Administrator, and Leah Figaro, Human Resources Manager, and explained the purpose of the visit.

On 5/11/22, from 2:37pm to 4:00pm, Licensing Program Analyst (LPA) Darlene Chavez conducted an unannounced case management visit to the facility. 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 Community Care Licensing (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. LPA interviewed the Administrator and obtained documentation pertinent to the investigation. LPA determined further investigation was needed. On 05/11/22, this case was referred to the CCL Investigations Branch (IB) and assigned to Investigator Elisia Rippe.

Investigator Rippe contacted the San Luis Obispo Police Department (SLO PD) from 05/16/2022 to 06/06/2022 regarding the status of the investigation and to schedule joint interviews with witnesses. On 06/07/2022, at 10:30am and 11:37am, Investigator Rippe and SLO PD Detective Chris Chitty conducted interviews with the Administrator; at 10:47am and 11:20am, with R1’s representative; at 10:56am with R1; and at 11:46am, with S1. In addition, Investigator Rippe also reviewed Long Term Care Ombudsman (LTCO) reports and facility file documents related to R1.

Continued on 809-D.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2022
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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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
VISIT DATE: 07/20/2022
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On 05/10/2022, at approximately 9:00am, S1 went into R1’s room and observed S2 hovering over R1 with R1’s shirt pulled up and kissing R1’s breast. R1 stated they told S2 they did not want S2 to touch R1. The facility personnel asked S2 to leave the resident’s room. S2 attempted to visit R1’s room again. Facility personnel then escorted S2 out of the facility and contacted SLO PD law enforcement. S2’s employment with the facility was terminated effective 05/10/2022. On 05/11/2022, the facility self-reported that R1 disclosed that they were inappropriately touched by S2. The outcome of the SLO PD investigation is currently pending.

Based on the information obtained through the LTCO report and joint interviews conducted with SLO PD, Investigator Rippe determined there was sufficient evidence to support a substantiated finding. Therefore, the allegation “Sexual Abuse – Facility Staff #2 (S2) inappropriately touched facility Resident #1 (R1)” is deemed Substantiated at this time.

Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 809-D).

Exit interview conducted, appeal rights provided, a copy of this report issued.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/20/2022 12:31 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
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: 07/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/21/2022
Section Cited

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Additional Personal Rights of Residents in Privately Operated Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be free from neglect...and verbal, mental, physical, or sexual abuse. This requirement is not met as evidenced by:
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Based on interviews and police record review, the licensee did not comply with the above section because S2 inappropriately touched R1, which posed an immediate 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: 07/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2022
LIC809 (FAS) - (06/04)
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