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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850002
Report Date: 10/05/2023
Date Signed: 10/06/2023 07:34:36 AM

Document Has Been Signed on 10/06/2023 07:34 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
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: 9DATE:
10/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:37 AM
MET WITH: Licensee / Abiy TesfazgyTIME COMPLETED:
04:15 PM
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 At 10:10am on 10/05/2023, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to conduct the annual inspection visit.. LPA met with Licensee Abiy Tesfazgy, announced who he is and the reason for the visit. LPA additionally conducted a complaint investigation of the facility on this visit on a separate report.
At 11:45am Licensee and LPA conducted a walking tour of the physical facility. The the facility is located in a rural location and has a well for water. The well water is tested annual by Miller drilling and the last test was conducted in May of 2023. The front grounds are larger with areas for sitting and tables with umbrellas for shade. The back yard is large and enclosed by a fence with self latching gates on both sides of the yard. The facility is a 10 bedroom, 4 bathroom, large kitchen, large living room, dining room and two day rooms on each side of the facility. There is a staff office. Medications are secured and locked in the pantry colset in the kitchen. The facility has a first aide kit in the pantry that meets regulation requirements. LPA noted that room in the facility all have proper lighting, storage, and linin per regulation standards. LPA noted that the bathrooms have non skid mats, liquid soap and paper towels. LPA noted that all exits, doors and passage ways were free and clear of obstructions. LPA noted smoke detectors working throughout the facility. LPA noted that 1 of 3 carbon monoxide detectors had dead batteries that were replaced during inspection. Licensee stated carbon monoxide detectors will all be replaced by plugin carbon monoxide detectors within 24 hours of this inspection. LPA noted fire extinguisher in the kitchen was currently tagged and in the green range indicating good. LPA noted that the facility was generally clean and in good repair. LPA observed more than 2 days of perishable foods and more than 7 days of non-perishable foods on hand at the facility. And found no citations or violations during he physical inspection tour.
Licensee and LPA competed full care tools review. LPA noted that a technical advisory (ta) was issued for the dead batteries in the carbon monoxide detector. And a technical violation (tv) was issued for not reporting current resident under hospice care to Licensing. No other technical, citation or violation was issued during this annual inspection.
Exit interview, ta and tv issued, report read, and report provided.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE: DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/05/2023
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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