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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405802306
Report Date: 02/27/2026
Date Signed: 02/27/2026 04:18:27 PM

Document Has Been Signed on 02/27/2026 04:18 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:VISTA ROSA ELDER CAREFACILITY NUMBER:
405802306
ADMINISTRATOR/
DIRECTOR:		RACHELLE TELLEZFACILITY TYPE:
740
ADDRESS:467 HILL STREETTELEPHONE:
(805) 586-2200
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93401
CAPACITY: 25CENSUS: 19DATE:
02/27/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:15 PM
MET WITH:Jessica BaileyTIME VISIT/
INSPECTION COMPLETED:
04:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) De Leon conducted a case management-incident visit to the facility above.
LPA met with back up Administrator Jessica Bailey and explained the purpose of the visit.

Community Care Licensing (CCL) received a self reported incident report from the facility dated 12/10/2025. LPA De Leon received a telephone call from Administrator Rachelle Tellez on 12/10/2025 reporting resident 1(R1) and resident 2 (R2) had an incident where a personal trainer contracted by resident 2(R2) was involved in kicking R1's walker back so R1 could not push R1's walker into R2's wheelchair.

On 02/05/2026 Administrator Rachelle Tellez sent LPA De Leon a copy of the video surveillance she had sent to LTCO of the incident. LPA De Leon reviewed the video surveillance and it was found that the personal trainer of R2 was left alone with both R1 and R2 in a common area of the facility. The personal trainer as a contractor hired by R2 was not able to be left alone with R1 and no staffing of the facility was present at the exact time of the incident, staffing immediately came into the common area as soon as the incident had ended.

The personal trainer that was contracted by R2 was not on the facility approved Guardian roster for CCL and therefore should not have been left alone with R1 in care without being associated to the facility Guardian roster.

Exit interview conducted, deficiency cited, civil penalty assessed, copy of report and appeal rights printed for Administrator.
NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Rachael De Leon
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 02/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/27/2026
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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Document Has Been Signed on 02/27/2026 04:18 PM - It Cannot Be Edited


Created By: Rachael De Leon On 02/27/2026 at 03:56 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: VISTA ROSA ELDER CARE
FACILITY NUMBER: 405802306

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/27/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/02/2026
Section Cited
HSC
1569.17(b)(2)(C)

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(b)...(2) The following persons are exempt from requirements applicable under paragraph (1):(C) A third-party contractor retained by the facility if the contractor is not left alone with clients in care. This requirement was not met as evidenced by:
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Administrator agreed to read and have a full undersading of H&S code 1569.17 and trian staff on the H&S code, provide proof of trianing to CCL.
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Based on video surveillance the Licenesee did not comply witht the regulation above the personal trianer higher by R2 did not have a clearance to be left alone with R1 which possess an immediate health and saefty risk for residnets in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kelly Burley
NAME OF LICENSING PROGRAM MANAGER:
Rachael De Leon
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2026


LIC809 (FAS) - (06/04)
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