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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405850002
Report Date: 07/11/2024
Date Signed: 07/11/2024 11:45:36 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/26/2024 and conducted by Evaluator Mark Jeffries
COMPLAINT CONTROL NUMBER: 29-AS-20240626131239
FACILITY NAME:YELLOW ROSE ASSISTED LIVINGFACILITY NUMBER:
405850002
ADMINISTRATOR:TESFAZGY, ABIYFACILITY TYPE:
740
ADDRESS:4225 CAMP 8 RDTELEPHONE:
(805) 286-8477
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY:15CENSUS: 10DATE:
07/11/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH: Licensee - Abiy TesfazgyTIME COMPLETED:
12:01 PM
ALLEGATION(S):
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Facility in disrepair.
INVESTIGATION FINDINGS:
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 At 10:00am on 07/11/2024 Licensing Program Analyst (LAP) Jeffries arrived unannounced to the facility to deliver final findings to the allegations to this complaint. LPA met with Licensee, Abiy Tesfazgy, annoucned who he is and the reason for the visit. LPA conducted a coursory tour the the facility.

As to the allegation of, “Facility in disrepair.” It was alleged that the facilities kitchen sink, and thermostat for half of the facility's HVAC unit have been inoperable for months. It was discovered through interviews, observation and documentation that on 07/01/2024, LPA Jeffries conducted interviews of 4 of 10 residents. R1- R4 all stated that the facility gets warm, and the administrator provides fans. On 07/01/2024 LPA observed the north side of the facility to be blowing air, however the air was not conditioned to be cold. LPA noted and photographed the thermometer placed on the south side of the facility to be 82* (f) at 10:56am on date of visit.

CONTINUED on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 29-AS-20240626131239
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 LIVING
FACILITY NUMBER: 405850002
VISIT DATE: 07/11/2024
NARRATIVE
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LPA Jeffries interview with Administrator on 07/01/2024, who indicated that the kitchen sink was recently fixed, and the facilities air conditioner was scheduled to be repaired on 07/03/2024. LPA noted that on 07/05/2024 LPA contacted Administrator by phone to confirm repair. On 07/11/2024 LPA Jeffries conducted a visit to facility to confirm that facility sink and air-condition had be repaired. At this time there is enough evidence to support that during the time of the complaint the facility was in disrepair, therefore the allegation of, “Facility in disrepair.” Is substantiated at this time.


Exit interview, report read, appeal rights and report provided.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20240626131239
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 LIVING
FACILITY NUMBER: 405850002
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/11/2024
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and
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Licencee agrees to promt repair of failing facility appliances and utilities in a timely manor. .
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visitors this requiorment was not met by evidence of Air Condition not fuctioning properly for an extened period of time. What places residents in potental danger.
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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.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/26/2024 and conducted by Evaluator Mark Jeffries
COMPLAINT CONTROL NUMBER: 29-AS-20240626131239

FACILITY NAME:YELLOW ROSE ASSISTED LIVINGFACILITY NUMBER:
405850002
ADMINISTRATOR:TESFAZGY, ABIYFACILITY TYPE:
740
ADDRESS:4225 CAMP 8 RDTELEPHONE:
(805) 286-8477
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY:15CENSUS: 10DATE:
07/11/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH: Licensee - Abiy TesfazgyTIME COMPLETED:
12:01 PM
ALLEGATION(S):
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Facility staff not using proper infection control practices.
Facility staff does not provide a good quality of food to residents in care.
Facility staff do not meet the needs of resident in care.
INVESTIGATION FINDINGS:
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 At 10:00am on 07/11/2024 Licensing Program Analyst (LAP) Jeffries arrived unannounced to the facility to deliver final findings to the allegations to this complaint. LPA met with Licensee, Abiy Tesfazgy, annoucned who he is and the reason for the visit. LPA conducted a coursory tour the the facility.

As to the allegation of, “Facility staff not using proper infection control practices.” It was alleged that facility did not have a supply of gloves on hand for infection control procedures. On 07/01/2024, LPA Jeffries conducted interviews of Staff 1 (S1) and S2, both S1 and S2 deny being short or out of gloves or any Personal Protective Equipment (PPE) at in time in the last 12 months. On 10/05/2023 LPA Jeffries conducted full facility annual inspection and observed an ample amount of supply of gloves for a facility licensed for 15 residents. On 07/01/2024, LPA Jeffries observed 20 boxes of assorted size gloves, each box containing 100 gloves per box (600 pairs of gloves on hand). On 07/01/2024, LPA Jeffries interviewed 4 of 10 residents R1, R2, R3, and R4, who all stated they had no issues with this facility and feel safe and comfortable in this facility. CONTIUNUED on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 29-AS-20240626131239
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 LIVING
FACILITY NUMBER: 405850002
VISIT DATE: 07/11/2024
NARRATIVE
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 At this time there is not enough evidence to support the allegation of, “Facility staff not using proper infection control practices.” and is unsubstantiated at this time.

As to the allegation of, “Facility staff does not provide a good quality of food to residents in care.” It was alleged that the facility does not provide good quality/fresh food. On 07/01/2024, LPA Jeffries interviewed 4 of 10 residents, R1, R2, R3, and R4, who all stated they had no issues with food and no issues with this facility and feel safe and comfortable in this facility. On 10/05/2023 LPA Jeffries conducted full facility annual inspection and observed 2 days of perishable and 7 days of non-perishable foods on hand at the facility for 15 residents and staff. On 07/01/2024 LPA Jeffries interviewed S1 and S2 who stated that the facility administrator has never been short on quality foods. On 06/27/2024 LPA Jeffries conducted an interview of a reliable source [Witness 1, W1] (individual with credential or license to signify expertise in this field.) who visits and observes this facility on a bi-weekly basis. W1 stated that for the last year the facility has had quality foods in sufficient amounts. On 07/01/2024, LPA Jeffries observed at least 2 days of perishable and at least 7 days of non-perishable foods on hand that were of good quality and amounts. At this time there is not enough evidence to support the allegation of. ““Facility staff does not provide a good quality of food to residents in care.” and is unsubstantiated at this time.

As to the allegation of, “Facility staff do not meet the needs of resident in care.” It was alleged that the facility is unkept, facility has no activities, and residents have been bitten by fleas. It was discovered through interviews, documentation, and observation that on 07/01/2024 LPA Jeffries interviewed 4 of 10 Residents, R1 -R4 all denied having any bug bites on their bodies. R1 – R4 all stated that staff do a good job of keeping the facility clean. R1- R4 all stated that the facility provides activities daily for all residents. R1- R4 all stated that they had no issues with the facility. On 07/01/2024 LPA Jeffries interviewed S1 and S2, who both stated that facility clean up is a normal party of their daily duties and have never had any issues with completing all daily duties. S1 and S2 deny any indication of residents or staff suffering from any bug bites. On 07/01/2024 LPA Jeffries toured the facility and found the facility to be clean. On 10/05/2023 LPA Jeffries conducted an unannounced annual inspection, and the facility was observed to be clean during that annual inspection. LPA Jeffries reviewed facility weekly activities schedule and noted that activities were observed during annual inspection on 10/05/2023. At this time there is not enough evidence to support the allegation of, “Facility staff do not meet the needs of residents in care.” and is unsubstantiated at this time.
Exit interview, report read, and report provided.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5