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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405802306
Report Date: 04/10/2024
Date Signed: 04/10/2024 10:53:50 AM


Document Has Been Signed on 04/10/2024 10:53 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:VISTA ROSA ELDER CAREFACILITY NUMBER:
405802306
ADMINISTRATOR:RACHELLE TELLEZFACILITY TYPE:
740
ADDRESS:467 HILL STREETTELEPHONE:
(805) 586-2200
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93401
CAPACITY:25CENSUS: 19DATE:
04/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Jessica Bailey, AdministratorTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Miller arrived at 10:15 am to conduct a 1 year annual visit to the facility above. LPA met with Administrator, Jessica Bailey and explained the purpose of the visit.

LPA took a tour of the interior of the facility.

LPA will need further time to complete the annual visit and will return at a later date.

Exit interview conducted and copy of report printed for Administrator.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Erika MillerTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:
DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2024
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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