405850513-7-19-2024-29-AS-MJES-D7BRSE-20240719131636

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405850513
Report Date: 07/19/2024
Date Signed: 07/19/2024 01:16:53 PM

Document Has Been Signed on 07/19/2024 01:16 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:	CUESTA ROSA SENIOR RESIDENCE		FACILITY NUMBER:	405850513
ADMINISTRATOR/ DIRECTOR:	BAILEY, JESSICA		FACILITY TYPE:	740
ADDRESS:	1691 FREDERICKS STREET		TELEPHONE:	(805) 457-9824
CITY:	SAN LUIS OBISPO	STATE: CA	ZIP CODE:	93401
CAPACITY: 40		CENSUS: 0	DATE:	07/19/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:48 AM
MET WITH:	Administrator, Jessica Bailey		TIME VISIT/ INSPECTION COMPLETED:	01:39 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	At 9:00am on 07/19/2024, Licensing Program Analysts (LPA's) De Leon and Jeffries arrived at the appointment time to conduct the Pre-Licensing visit. LPA's met with Administrator, Jessica Bailey and announced the purpose of the visit. This facility is a brand new build, two story building that has 36 resident rooms with 36 bathrooms and one being a shared bathroom. 2 common area restrooms and 1 staff restroom.32 rooms have been designated for double occupancy. The fire clearance is approved for a maximum of 40 bedridden residents. The facility is completely fenced with a drive up automatic gate for entry of vehicles and a pedestrian gate the automatically opens and shuts. The facility has an automatic vehicle exiting gate with a pedestrian gate that opens and shuts automatically. The first floor front entrance has a receptionist desk, 10 resident rooms, three staff offices, locked medication room, large living room, kitchen, one locked storage room, three locked doors to two mechanical rooms, a locked staff locker room with restroom, locked laundry room, dining room, dinette room, and a courtyard in the center of the facility with dining room access and the 1st floor residents have patio door access. The courtyard has a large outdoor fireplace in need of a screening. The second floor has 26 residents rooms with 11 rooms having balconies, a large activity room with a small staff office, a beauty parlor, 2 locked storage closets, 1 housekeeping closet, and a back courtyard on the second floor with seating and shaded areas for residents and visitors use. The 2nd floor has a large fenced in patio/balcony with furniture and umbrella for shade. LPA reviewed facility emergency evacuation plan and infection control plan to be within regulation requirements. CONTINUED on LIC809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: CUESTA ROSA SENIOR RESIDENCE	FACILITY NUMBER: 405850513
	VISIT DATE: 07/19/2024

NARRATIVE

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Administrator and LPA conducted a full physical tour of the facility. LPA's noted that water on both floors were tested and within regulations parameters on this pre licensing visit. The kitchen has all new appliances, and refrigerator and freezer are within required regulation temperatures. LPA's inspected 10 resident rooms 100, 103, 109, 200, 201, 202, 206, 211, 214, and 223 which had appropriate furnishing and linen, bathrooms had non-slip mats, secured grabs are present, all plumbing is working properly. LPA's observed the large activities with ample room for activities indoors and outdoors. Kitchen is clean, safe and sanitary. The facility has emergency food and water supply. The facility has 7 days on Non-perishable and with stock two days of perishables prior to accepting residents in care. The facility has plenty of hygiene and grooming products, EPA approved disinfectant and cleaning supplies.

Administrator and LPA's conducted a full review of the pre licensing care tools. LPA's noted that there were no violations, citations or technical violations observed during the full review of the pre-licensing care tools modules. Licensing Program Manager waived COMP III component training on LIC812 due to Administrator has additional facilities currently licensed.

Pre licensing is incomplete at this visit, facility courtyard fire place needs screening. Products order, installer scheduled, verified by LPA's for 07/21/2024. LPA De Leon will follow up on 07/22/2024 completion of fire place screening resolution and will document upon completion verification.

Exit interview, report read, and report provided. .

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024

LIC809 (FAS) - (06/04)

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