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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405801779
Report Date: 11/13/2025
Date Signed: 11/13/2025 03:52:29 PM

Document Has Been Signed on 11/13/2025 03:52 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:CASA ROSA ELDER CAREFACILITY NUMBER:
405801779
ADMINISTRATOR/
DIRECTOR:		ROXANDRA WHITESTINEFACILITY TYPE:
740
ADDRESS:2172 S. HALCYON ROADTELEPHONE:
(805) 473-0306
CITY:ARROYO GRANDESTATE: CAZIP CODE:
93420
CAPACITY: 22CENSUS: DATE:
11/13/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Rachelle Tellez, Back up AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) De Leon arrived at 1:30 pm to conduct a 1 year annual visit to the facility above. LPA met with back up Administrator Rachelle Tellez and explained the purpose of the visit.
A tour of the inside and outside of the facility was conducted. The following was inspected and noted during the annual visit:
Infection Control: The facility has a current Infection Control Plan. The facility has a sign in and out binder for visitors at entry with hand sanitizer. The bathrooms have toilet paper, paper towels, and hand soap. Quarantined or isolated individuals will have meals and medication delivered to rooms. Staff are trained on infection control and the use of Personal Protective Equipment (PPE).
Operational Requirements: The facility has a current plan of operation on file with the department. The Facility is operating in compliance with the granted fire clearance. The facility has current liability insurance and expires in April 2026. The facility is approved for a capacity of 22. The fire clearance is granted for 22 Non-Ambulatory of which 18 may be bedridden and Hospice is approved for 8.
Physical Plant & Environment Safety: The fire extinguishers were last charged and inspected on July 14, 2025. The facility is a 17 bedroom, 13 resident bathrooms and 3 common areas restrooms, 2 living rooms, 2 kitchens, 2 dining rooms, activity room, 2 laundry rooms, staff area with lockers, and beauty parlor. The facility is currently occupying 15 residents in care and employs 20 staff and 2 Administrators. LPA was authorized to enter and inspect facility. The facility has smoke and carbon monoxide detectors. The lighting and lamps are sufficient for the use of the facility and for resident comfort. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The showers have non-skid mats. The pathways are clear of any obstructions. Facility is well lit inside and outside. Disinfectant, cleaning solutions and poisons are inaccessible to residents in care and locked in cupboards and closets. Continued 809-C
NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Rachael De Leon
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/13/2025
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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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: CASA ROSA ELDER CARE
FACILITY NUMBER: 405801779
VISIT DATE: 11/13/2025
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The facility has sufficient space inside and outside for activities and visiting. The facility has plenty of shade. The facility has telephone and internet service for resident use. The stairway carpeting to both stairwells is in need of carpet cleaning, Administrator has appointments to have it completed. The facility has emergency chairs for stairwells. Fireplaces have screened covers for safety.
Resident Rights/Information: The facility had postings for Personal Rights and non- discrimination, Emergency Disaster plan, Facility sketch, Visiting policy with hours, Rights to Resident Council and family council, CCL PINS, and CCL reports. All postings were posted at front entry or in the common areas of the facility. CCL and LTCO complaint posters are posted.
Planned Activities: The facility has a large room for activities and plenty of supplies for activities in two large cupboards, any items that can pose a danger were inaccessible to residents in care. The facility has an activity calendar posted in several areas.
Food Service: The facility handles and prepares food safely. The facility has 2 day perishables and 7 day non-perishables to meet the food service requirement. The freezer is kept at 0 degrees and the refrigeration is kept at 40 degrees or lower. All food is covered, stored and marked appropriately. Cleaning solutions and equipment are stored separately from food supplies. The facility has additional food and water for an emergencies.
Incidental Medical and Dental: The facility provides or assist in providing transportation to medical and dental appointments. The facility has a locked medication room for all centrally stored medications, PRN medications, and first aid supplies. Medication room has a red sharps container for disposal. Administrator and another staff work together to destroy medication at facility when required. The facility uses an electronic Medication Administrator Record (MAR) and uses the Centrally Stored Medication and Destruction Record (CSMDR). All medications were audited for expiration dates, altered labels and medications stored in original containers, no deficiencies found.
Residents with Special Health Needs: The facility does accept dementia residents in care. Facility does not currently have any residents using oxygen. The facility currently has hospice residents in care, plans are kept on file. The facility currently has residents receiving Home Health services and plans are kept on file. The facility does not have delayed egress. The facility has a large driveway with gate at entry and a calling system to access gate for car entry. The facility has a court yard at entry with a self closing gate. The property has other buildings on the premises but are not part of the license.
LPA will return at a later date to review records and conducted interviews.
Exit interview conducted and copy of report printed for Administrator.
NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Rachael De Leon
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2025
LIC809 (FAS) - (06/04)
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