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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850002
Report Date: 07/01/2024
Date Signed: 07/01/2024 12:59:26 PM

Document Has Been Signed on 07/01/2024 12:59 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:YELLOW ROSE ASSISTED LIVINGFACILITY NUMBER:
405850002
ADMINISTRATOR/
DIRECTOR:		TESFAZGY, ABIYFACILITY TYPE:
740
ADDRESS:4225 CAMP 8 RDTELEPHONE:
(805) 286-8477
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY: 15CENSUS: 10DATE:
07/01/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:06 AM
MET WITH:Care Giver - Elsa GebretensaeTIME VISIT/
INSPECTION COMPLETED:
11:47 AM
NARRATIVE
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 At 9:00am on 07/01/2024, Licensing Program Analyst (LPA) Jeffries arrived at the facility unannounced to address allegations on a separate complaint. Upon screening of care staff, LPA Jeffries discovered that Staff 1 (S1) was not cleared to work at the facility. LPA ran S1 through Guardian, and LIS background checks and did not find S1 on facilities rosters, or by name, date of birth, or social security number in Guardian system. LPA Jeffries requested that S1 leave the facility due to not being a cleared staff. A citation was issued for uncleared staff for the total of the 3 days the staff had been working at the facility. The 3 days of work was verified by interview with S1 and interviews on 07/01/2024 with S2 and S3 during the investigation visit on 07/01/2024.

Exit interview, report read, citation and civil penalty issued, appeal rights and report provided.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE: DATE: 07/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/01/2024
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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Document Has Been Signed on 07/01/2024 12:59 PM - It Cannot Be Edited


Created By: Mark Jeffries On 07/01/2024 at 09:56 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: YELLOW ROSE ASSISTED LIVING
FACILITY NUMBER: 405850002

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/01/2024
Section Cited
CCR
87355()

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87355 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: This requirement was not met by evidence of S1 not being
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Licensee agrees to have S1 fingerprint cleared and provide proof of clearance to LPA as soon as S1 has been cleared to work through the fingerprint clearance process. (mark.jeffries@dss.ca.gov)
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fingerprint cleared to work at this facility, which put Resident in iminate risk.
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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 Burley
LICENSING EVALUATOR NAME:Mark Jeffries
LICENSING EVALUATOR SIGNATURE:
DATE: 07/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2024


LIC809 (FAS) - (06/04)
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