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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
405801779
Report Date:
01/17/2020
Date Signed:
02/02/2023 03:05:10 PM
Document Has Been Signed on
02/02/2023 03:05 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
,
6500 HOLLISTER AVE. SUITE 200
GOLETA
,
CA
93117
FACILITY NAME:
CASA ROSA ELDER CARE
FACILITY NUMBER:
405801779
ADMINISTRATOR:
ARPAD SOO
FACILITY TYPE:
740
ADDRESS:
2172 S. HALCYON ROAD
TELEPHONE:
(805) 473-0306
CITY:
ARROYO GRANDE
STATE:
CA
ZIP CODE:
93420
CAPACITY:
22
CENSUS:
18
DATE:
01/17/2020
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
12:27 PM
MET WITH:
Jessica Bailey/Administrator
TIME COMPLETED:
04:13 PM
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SUPERVISORS NAME
:
Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME
:
Mark Jeffries
LICENSING EVALUATOR SIGNATURE
:
DATE:
02/07/2020
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
02/07/2020
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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