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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405802285
Report Date: 07/12/2021
Date Signed: 07/12/2021 06:33:34 PM

Document Has Been Signed on 07/12/2021 06:33 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:ROSE GARDENFACILITY NUMBER:
405802285
ADMINISTRATOR:DIANA BARNHILLFACILITY TYPE:
740
ADDRESS:6100 LOS GATOS ROADTELEPHONE:
(805) 466-2506
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY: 6CENSUS: 3DATE:
07/12/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Diana Barnhill, AdministratorTIME COMPLETED:
12:50 PM
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At 11:15 am, on 07/12/2021, Licensing Program Analyst (LPA) Darlene Chavez conducted an unannounced annual infection control inspection of the facility above. LPA and administrator toured the facility. LPA's initial tour of the facility resulted in observations which were immediately addressed by the administrator: At 12:19 pm, administrator committed to post CDSS PINS or summaries. At 12:27 pm, administrator posted the Emergency Contact Information page in the facility. All other areas of the facility are in good working order, resident and staff files and medications are in locked cabinets or closets, The facility is kept at a comfortable temperature of 74 F degrees. One (1) fire extinguisher is full and was inspected on 4/22/2021.

At 11:35 am, LPA Chavez conducted Infection Control mitigation module with administrator. Administrator was instructed to immediately train staff on N95 fit testing. No other corrections found in mitigation module..

Exit interview conducted and report emailed.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2021
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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