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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425801617
Report Date: 07/11/2023
Date Signed: 07/11/2023 05:27:21 PM

Document Has Been Signed on 07/11/2023 05:27 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: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: 0DATE:
07/11/2023
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
05:00 PM
MET WITH:Rose Angkahan, AdministratorTIME COMPLETED:
05:30 PM
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Licensing Program Analyst (LPA) Jenny Olson conducted a Case Management Closure visit to the facility above on 7/11/2023 at 05:00pm.

LPA toured the inside and outside of the facility. LPA observed no evidence of residents or staff on site.

LPA observed one private renter who stated they are just renting a room and does not require care or supervision.

Exit interview conducted and copy of report was printed.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE: DATE: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2023
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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