405802259-10-15-2025-29-AS-RDLN-DMGS3Y-20251015133156

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405802259
Report Date: 10/15/2025
Date Signed: 10/15/2025 01:33:15 PM

Document Has Been Signed on 10/15/2025 01:33 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 ROSE		FACILITY NUMBER:	405802259
ADMINISTRATOR/ DIRECTOR:	GERMAIN, ANDRIANNA		FACILITY TYPE:	740
ADDRESS:	1555 LAUREL LANE		TELEPHONE:	(805) 439-4774
CITY:	SAN LUIS OBISPO	STATE: CA	ZIP CODE:	93401
CAPACITY: 6		CENSUS: 4	DATE:	10/15/2025
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:30 AM
MET WITH:	Jessica Bailey, Back up Administrator		TIME VISIT/ INSPECTION COMPLETED:	01:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) De Leon made an unannounced Case Management Continuation Annual visit to the facility listed above. LPA met with Rachelle Tellez, Back up Administrator and explained the purpose of the visit. A tour of the physical plant was assessed, and the following was noted: Resident Rights & Information: LPA observed the license posted, Complaint Poster, Bill of Rights and Right to Residential Council, non-discrimination statement, and resident rights off the entry in the hall near kitchen. Infection Control: The facility has an infection control plan on file. The facility has PPE supplies and trains staff upon hire and annually thereafter. Medications and meals can be delivered to rooms when and if needed. Operational Requirements: The Facility is operating in compliance with the fire clearance. The facility has a license for 6 Non-Ambulatory which 1 may be bedridden in room 3. The facility provided current up to date liability insurance. All Dementia requirements are being met. Hospice wavier granted for 3. Planned Activities: Living room, dining room, and outside area with sufficient space for activities and visiting. The facility has games, magazines, book and planned activities with residents in care. Residents take part in any activity they want to. Food Service: The kitchen and pantry were sufficiently stocked with two day perishable and seven day non-perishables. Foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Emergency supply of food and water is available. Garbage cans have tight fitting covers. Refrigerator is kept at 40 F or below and the freezer at 0 F degrees. The kitchen chemicals are locked under the sink. There is a locked drawer for sharps and knives. Continued 809-C

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Rachael De Leon
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/15/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2025

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: CHATEAU ROSE	FACILITY NUMBER: 405802259
	VISIT DATE: 10/15/2025

NARRATIVE

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Physical plant: Facility was checked for cleanliness and condition. Walls, windows, ceilings, floors, floor coverings, and doors were checked, all in good condition. The facility maintains a comfortable temperature. The facility has 6 bedrooms designated for residents use with on suite bathrooms currently occupying 4 residents. The facility has an upstairs designated for staff only with 3 bedrooms/2 bathrooms for live in staff and 1 locked medication room with a locked medication cart. The facility is clean, safe, and sanitary. The outdoor area of the facility has outdoor furniture with shade for residents and visitors. There are gardens and walking paths. There is a locked jacuzzi with a hard top. The facility has a fenced in pool with two locked gates. Resident rooms are adequately dressed with sheets, pillowcase, mattress pad, and blankets which are in good condition. There is at least one chair, night stand, and sufficient lighting for each resident. There is enough linen available to change weekly or more, if needed. Storage cabinets have enough personal hygiene product which is provided by the licensee and all cleaning products, toxins are stored and locked away inaccessible to residents in care. Bathrooms were checked for cleanliness, secured grab bars and proper operation. All clients have their own personal restroom with proper hand washing sign, soaps, and paper towels.
Incidental Medical and Dental: Medications are centrally stored in the locked medication room upstairs, and double secured in a locked medicine cabinet. Medications are checked for expiration dates, in original containers and no labels were altered. The facility uses the Medication and Destruct Records (CSMDR) and the Medication Administration Record (MAR).
Residents with Special Health Needs: The facility does accept dementia residents in care. All items that could pose a danger such as sharps, and cleaners were locked separately in drawers and cupboards. The facility does not have delayed egress. The facility does have hospice and home health visits to the facility for residents in care and plans are kept up to date. There are no residents currently on oxygen. The facility is completely fenced with a large front entry/exit gate, sign is posted at gate for opening for pedestrians.
Emergency Disaster Preparedness: The plan is current, and forms were posted. The facility provides disaster drills quarterly. The fire extinguishers were charged and tagged on March 15, 2025. Fire extinguishers are located in the kitchen and the hallway closet by front entry. The dual smoke and carbon monoxide detectors are present and hard wired throughout the facility.

LPA interviewed 2 staff, residents were eating lunch and resting did not want to interview.
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: 10/15/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2025

LIC809 (FAS) - (06/04)

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