405850002-10-30-2025-29-AS-GHTO-DMXRF7-20251030125840

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405850002
Report Date: 10/30/2025
Date Signed: 10/30/2025 12:58:56 PM

Document Has Been Signed on 10/30/2025 12:58 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	YELLOW ROSE ASSISTED LIVING		FACILITY NUMBER:	405850002
ADMINISTRATOR/ DIRECTOR:	TESFAZGY, ABIY		FACILITY TYPE:	740
ADDRESS:	4225 CAMP 8 RD		TELEPHONE:	(805) 237-2440
CITY:	PASO ROBLES	STATE: CA	ZIP CODE:	93446
CAPACITY: 15		CENSUS: 9	DATE:	10/30/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:20 AM
MET WITH:	Administrator - Abiy Tesfazgy		TIME VISIT/ INSPECTION COMPLETED:	01:00 PM

NARRATIVE

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On 10/30/2024, at 9:20am, Licensing Program Analyst (LPA) Haner-Tomasko 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 and Administrator 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 of the facility. The backyard is large and enclosed by a fence with self-latching gates on both sides of the yard. The facility has 10-bedrooms, 3 bathrooms, a large kitchen, large living room, dining room. There is a staff office. The facility has battery operated and wired smoke detectors in each room that were inspected by Alpha Fire Inspection on 12/3/2024. LPA observed fire extinguishers throughout the facility that were tagged current and in the green compression range, serviced on 11/20/2024. LPA tested facility hot water at 105*(f), within regulation temperatures 105*-120* (f). LPA observed at least 2-days of perishable and at least 7-days of nonperishable foods. During the facility tour in the kitchen at 9:30am LPA noted approximately nine steak knives in the designated knife drawer and the magnetic lock broken and not functioning. At 9:32am LPA observed four lighters in a drawer next to the kitchen sink in an un-lockable drawer. At 9:58am the lockable door to the laundry room was noted to not close completely and the striker not lining up with the strike plate preventing the door from locking. Unlocked chemicals and paint were noted inside the Laundry room. LPA was unable to complete the facility annual and may return at a later date.

LPA and Administrator conducted a partial review of the annual care tool modules.

Exit interview conducted, deficiency cited on LIC809-D, report signed, and report provided to Administrator.

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Garrett Haner-Tomasko
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/30/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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Document Has Been Signed on 10/30/2025 12:58 PM - It Cannot Be Edited

Created By: Garrett Haner-Tomasko On 10/30/2025 at 12:44 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: YELLOW ROSE ASSISTED LIVING	FACILITY NUMBER: 405850002
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space and Access

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above when they left knives, poisonous chemical's and lighters unlocked and accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/31/2025
	Plan of Correction
1 2 3 4	Administrator was locking up the objucts as they were found. Administrator will text LPA photos and videos by tomorrow 10/31/2025 showing the drawers and laundry room door are repaired ensuring they lock and keep items inaccessible to residents in care. LPA will coduct staff training on this regulation and email LPA documentation and signed roster on or before 11/13/2025.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Kelly Burley
NAME OF LICENSING PROGRAM MANAGER:

	Garrett Haner-Tomasko
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/30/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2025

LIC809 (FAS) - (06/04)

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