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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850002
Report Date: 10/14/2024
Date Signed: 10/14/2024 03:18:28 PM

Document Has Been Signed on 10/14/2024 03:18 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: 11DATE:
10/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:25 AM
MET WITH:Licensee Abiy TesfazgyTIME VISIT/
INSPECTION COMPLETED:
01:26 PM
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At 9:30am on 10/14/2024, 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.

At 10:05am LPA conducted a walking tour of the physical facility. The facility is located in a rural location and has a well for water, sceptic tank for plumbing, and electricity is powered by grid electricity. The front grounds are larger with areas for sitting and tables with covered porch for shade. There are walking areas for the residents in the front for the facility. 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, 3 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 closet 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 nonskid mats, liquid soap and paper towels. LPA noted that all exits, doors and passageways were free and clear of obstructions. LPA noted smoke detectors working throughout the facility and working carbon monoxide detectors. 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. LPA noted that Licensee has a current Administrators Certificate that expires on 09/08/2025. LPA reviewed Resident, Staff and Medication records including Infection Control Plan and Emergency Disaster Plan. LPA noted that they found no citations or violations during this annual physical inspection tour.

Licensee and LPA competed full care tools review. No other citation or violation was issued during this annual inspection.

Exit interview, , report read, and report provided.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2024
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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