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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405802259
Report Date: 07/25/2023
Date Signed: 07/25/2023 06:01:04 PM

Document Has Been Signed on 07/25/2023 06:01 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:CHATEAU ROSEFACILITY NUMBER:
405802259
ADMINISTRATOR:SOO, ARPADFACILITY TYPE:
740
ADDRESS:1555 LAUREL LANETELEPHONE:
(805) 439-4774
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93401
CAPACITY: 6CENSUS: 5DATE:
07/25/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Jessica Bailey and Rachelle Tellez, AdministratorsTIME COMPLETED:
06:15 PM
NARRATIVE
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On 7/25/23 at 2:20 pm, Licensing Program Analyst (LPA) Chavez conducted an unannounced continuation visit to finalize the Annual/Required inspection started on 7/6/23. LPA met with Jessica Bailey, Administrator, and Rachelle Tellez, Administrator, and explained the purpose of the visit.

Medications are centrally stored in the locked room upstairs. Medications are properly labeled and checked for expiration dates. A sampling of resident’s medication show they are centrally stored prescription and PRN medication which have been logged in the medications record with proper documentation from the residents’ doctors. Proper medication dispensing instructions are followed and checked for contamination. First Aid has all proper items and is current.
Resident records were reviewed for requirements and legibility: LPA reviewed 5 residents’ files for Medical Assessments, Needs and Service plans, Signed Admission Agreements and Pre-appraisals. There were no issues with resident files reviewed. Planned activities are offered to residents in care.
Staff records were checked for expired or missing certificates and clearances: LPA conducted a file review of 5 staff for criminal record clearances/associations/and current First Aid. The Administrator file was reviewed for current first aid, fingerprint clearance, administrator certificate. All required training has been completed.

Due to technical errors in the CARE Tool during the initial 7/6/23 visit, the deficiencies and civil penalty pages did not print, therefore, LPA is creating the 809-D page and LIC421M Civil Penalty page and providing to the administrator today.

Exit interview conducted, deficiencies and civil penalty issued, and report and appeal rights given.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE: DATE: 07/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/25/2023
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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Document Has Been Signed on 07/25/2023 06:01 PM - It Cannot Be Edited


Created By: Darlene Chavez On 07/25/2023 at 05:41 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CHATEAU ROSE

FACILITY NUMBER: 405802259

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 07/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(e)
(e) Swimming pools and other bodies of water shall be fenced and in compliance with state and local building codes.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 out of 1 jacuzzi covers was not locked and accessible to residents in care which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2023
Plan of Correction
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The licensee has emptied the jacuzzi so there is no longer a danger to residents. No further action needed.
Type B
Section Cited
CCR
87705(f)(2)
Resident medications were found in an unlocked drawer in the kitchen. The drawer did not have a lock. Medications were daily dosages for today as the morning medications were empty and the noon, PM, and evening medications were still in the daily containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 6 out of 6 resident medications for the afternoon and evening were in an unlocked drawer in the kitchen and accessible to residents which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2023
Plan of Correction
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Licensee immediately removed the medications from the kitchen drawer. LPA observerd there were no medications in the drawer on 7/25/23. No further action needed.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Kelly Burley
LICENSING EVALUATOR NAME:Darlene Chavez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2023


LIC809 (FAS) - (06/04)
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