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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850002
Report Date: 10/08/2022
Date Signed: 10/08/2022 04:07:13 PM


Document Has Been Signed on 10/08/2022 04:07 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:TESFAZGY, ABIYFACILITY TYPE:
740
ADDRESS:4225 CAMP 8 RDTELEPHONE:
(805) 286-8477
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY:15CENSUS: 11DATE:
10/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Licensee / Abiy TesfazgyTIME COMPLETED:
04:15 PM
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At 12:30pm on 10/08/2022, Licensing Program Analyst (LPA) Jeffries arrived at the facility to conduct an annul infection control inspection. LPA announced who he was and the reason for the visit. Facility staff contacted Licensee Abiy Tesfazgy by phone. Licensee arrived at the facility a few minutes later, LPA explained to the Licensee the reason for the visit.
At 1:00pm Licensee and LPA conducted a cursory tour of the facility, The facility consists of a kitchen, dining room, 2 living rooms, 10 bedrooms, 2 resident bathrooms, a staff bathroom, office, and laundry room. The facility is on 6 acres of land. Also on the property are 2 locked sheds for storage and a barn. There are three water tanks on the property. There is outdoor furniture available for resident use and shade is available. All exits have auditory alarms to alert staff when someone enters or exits. Washer and dryer are present in facility. The facility is maintained in conformance with state fire marshal regulations. Smoke detectors and carbon monoxide detectors functioning and are hardwired throughout the facility, monitored 24 hours a day 7 days a week by Alpha Fire with quarterly functions testing by Alpha Fire. Fire extinguishers are fully charged. Inside and outside passageways are free from obstruction. There are no bodies of water on the facility property. The facility water with in regulation range between 95*-120*f. The facility had a very comfortable temperature at 73 degrees f when the outside temperature was 91*f. Residents rooms are appropriately furnished with adequate lighting and storage. LPA observed 2 days of perishable and 7 days of nonperishable foods. LPA observed the facility to be clean and in good repair free from hazards that present a danger to residents in care.
At 2:10pm Administrator and LPA conducted the infection control module of the annual inspection. LPA noted that there were no deficiencies noted on the infection control module of the annual inspection tool.
LPA also noted no deficiencies accessed on this annual visit.
Exit interview, report signed, and report emailed.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:
DATE: 10/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/08/2022
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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