405802306-5-4-2023-29-AS-DCHZ-CRHVYR-20230504165135

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405802306
Report Date: 05/04/2023
Date Signed: 05/04/2023 04:53:28 PM

Document Has Been Signed on 05/04/2023 04:53 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 CARE		FACILITY NUMBER:	405802306
ADMINISTRATOR:	BAILEY, JESSICA		FACILITY TYPE:	740
ADDRESS:	467 HILL STREET		TELEPHONE:	(805) 586-2200
CITY:	SAN LUIS OBISPO	STATE: CA	ZIP CODE:	93401
CAPACITY:	25	CENSUS: 19	DATE:	05/04/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:58 AM
MET WITH:	Jessica Bailey, Administrator		TIME COMPLETED:	05:10 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) Chavez made an unannounced Annual/Required visit to the facility above. LPA met with Administrator Jessica Bailey and Back-up administrator Rachelle Tellez and explained the purpose of the visit. A tour of the physical plant was assessed, and the following was noted: LPA observed the license posted, Complaint Poster, Bill of Rights and Right to Residential Council, non-discrimination statement, and resident rights on the hallway walls next to the staff office downstairs. The facility has 19 bedrooms and 22 bathrooms currently occupying 19 residents. Physical plant was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, and doors were checked, all in good condition. The facility maintains a comfortable temperature. The dual smoke and carbon monoxide detectors are hard wired along with a sprinkler system and is operational. Fire extinguishers located next to the entrance of the elevator, upstairs and downstairs, and in the kitchen were inspected on 05/04/23 and are charged in the green. There are no issues with Fire Clearance. Living room, dining room, and activity room furniture were checked and in good condition. The common rooms are clean, safe and sanitary. The courtyard of the facility has outdoor furniture, with shaded area for residents. There are no bodies of water. The kitchen area was sufficiently stocked with two-day perishable and seven-day non-perishables. The menu was posted for review. Snacks and beverages are available for residents in the facility when they want. Foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers. Refrigerators are kept at 40 F or below and freezers at 0 F degrees. Continued on 809-C.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

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: 05/04/2023

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
26
27
28
29
30
31
32

Resident rooms are adequately dressed with sheets, pillowcase, mattress pad, and blankets which are in good condition. There is at least one chair, nightstand and sufficient lighting for each resident. Resident rooms #3 and #13 have “No smoking, oxygen in use” signage on their doors, and the same sign is at the front entrance of the facility.
There is enough linen available to change weekly or more, if needed.
The Storage room has sufficient amounts of personal hygiene product which is provided by the licensee and all cleaning products, toxins are stored and locked away inaccessible to residents in care.
The bathrooms were checked for cleanliness and proper operation. The hot water temperature measured between 107.6 F and 111.17 F degrees in resident rooms 3, 6, 11, 13, and 17.
Medications are centrally stored in the locked medication room behind the administrative office. Medications are properly labeled and checked for expiration dates. A sampling of resident’s medication show they are centrally stored prescription and PRN medication which have been logged in the medications record with proper documentation from the residents’ doctors. Proper medication dispensing instructions are followed and checked for contamination. First Aid has all proper items and is current.
Resident records were reviewed for requirements and legibility: LPA reviewed 5 residents’ files for Medical Assessments, Needs and Service plans, Signed Admission Agreements and Pre-appraisals. There were no issues with resident files reviewed. Planned activities are offered to residents in care.
Staff records were checked for expired or missing certificates and clearances: LPA conducted a file review of 5 staff for criminal record clearances/associations/and current First Aid. The Administrator file was reviewed for current first aid, fingerprint clearance, administrator certificate. All required training has been completed.

Exit interview conducted, no deficiencies cited and report given.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2