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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425801617
Report Date: 02/10/2022
Date Signed: 02/10/2022 04:10:42 PM

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:ROSE CARE HOMEFACILITY NUMBER:
425801617
ADMINISTRATOR:ROSE ANGKAHANFACILITY TYPE:
740
ADDRESS:602 N. WESTERN AVE.TELEPHONE:
(805) 739-0764
CITY:SANTA MARIASTATE: CAZIP CODE:
93458
CAPACITY:6CENSUS: 1DATE:
02/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:23 PM
MET WITH:Rose Angkahan, Licensee/AdministratorTIME COMPLETED:
03:30 PM
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At 1:23 pm, on 2/10/2022, Licensing Program Analysts (LPAs) Darlene Chavez and Jenny Olson conducted an unannounced annual infection control inspection of the facility above. LPAs met with Rose Angkahan, Licensee/Administrator, and explained the reason for the visit. LPAs and licensee toured the facility.

LPAs’ initial tour of the facility resulted in observations which were immediately corrected. LPAs were screened upon entry to the facility by staff. Hand sanitizer was not visible upon entry. LPA Chavez instructed licensee to place hand sanitizer near the entryway. Licensee did so immediately. Between 1:35 pm and 1:45 pm, the kitchen water temperature was recorded at 105.7 F and the bathroom at 115.2 F. Licensee has family occupying bedrooms previously designated as resident rooms. Licensee will update the facility sketch and send to LPA Chavez. The facility has a CCLD Complaint Poster, however, it is an 11”x14”. Licensee will replace with regulation size 20”x26” and send a photo to LPA Chavez. Licensee and staff have not gone through training for proper PPE use. Licensee and staff will watch a video on proper donning and doffing of PPE and send a sign-in sheet to LPA Chavez.

At 2:15 pm, LPA Chavez conducted the Infection Control mitigation module with the licensee. No deficiencies were noted.

Exit interview conducted and report emailed to the licensee.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022
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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