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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850002
Report Date: 10/26/2021
Date Signed: 10/26/2021 06:56:44 PM

Document Has Been Signed on 10/26/2021 06:56 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:
10/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:25 PM
MET WITH:Abiy Tesfazgy, Administrator, Elsa Gebretensae, Caregiver, and Rebecca Griffin, CNA/CaregiverTIME COMPLETED:
04:57 PM
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At 3:25 pm, on 10/26/2021, Licensing Program Analyst (LPA) Darlene Chavez conducted an unannounced annual infection control inspection of the facility above. LPA informed caregivers Elsa Gebretensae and Rebecca Griffin of the reason for the visit. Administrator Abiy Tesfazgy was not at the facility and arrived at approximately 4:15 pm. LPA and Ms. Gebretensae toured the facility.

LPA’s initial tour of the facility resulted in observations which were immediately addressed by the administrator and facility staff: At 3:25 pm, LPA requested the facility screen LPA for COVID-19 upon entry to facility which was immediately conducted. At 3:27 pm, LPA observed that the sign-in sheet did not have temperatures recorded, and staff immediately added a column to record temperatures. At 4:00 pm, LPA noticed Provider Information Notices (PINs) or PIN summaries were not posted in the facility, and staff post them immediately. At 4:15 pm, staff said they have not been fit tested for N95 respirators. Administrator stated he will get fit tested and train staff by 11/03/21. At 4:32 pm, the current 8.5"x11" complaint poster was observed, and administrator will post a 20"x26" immediately.

At 4:00 pm, LPA conducted the Infection Control mitigation module with Caregiver Rebecca Griffin until Administrator Tesfazgy arrived. No deficiencies noted.

Exit interview conducted and report emailed to administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE: DATE: 10/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/26/2021
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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