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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405850002
Report Date: 03/16/2022
Date Signed: 03/16/2022 06:24:08 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/09/2022 and conducted by Evaluator Jeannette Olson
COMPLAINT CONTROL NUMBER: 29-AS-20220309160335
FACILITY NAME:YELLOW ROSE ASSISTED LIVINGFACILITY NUMBER:
405850002
ADMINISTRATOR:TESFAZGY, ABIYFACILITY TYPE:
740
ADDRESS:4225 CAMP 8 RDTELEPHONE:
(805) 286-8477
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY:15CENSUS: 10DATE:
03/16/2022
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Abiy Tesfazgy, AdministratorTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Facility staff is not following masking guidelines.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Olson conducted an unannounced 10-day complaint investigation visit to the facility above. LPA met with Abiy Tesfazgy, Administrator, and explained the purpose of the visit.

LPA toured the facility with staff and noticed one staff in the kitchen preparing lunch wearing a mask. LPA observed a second staff walking by also wearing a mask.

LPA interviewed Administrator, staff and resident (R1) regarding the allegation. Administrator interview revealed that staff always wear masks in the facility. Residents 1 (R1) interview stated the staff usually wear masks in the facility.

Continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 29-AS-20220309160335
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: YELLOW ROSE ASSISTED LIVING
FACILITY NUMBER: 405850002
VISIT DATE: 03/16/2022
NARRATIVE
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A credible witness (W1) stated on 3/8/2022, W1 observed a female caregiver in a wheelchair next to a sleeping resident with mask around chin. W1 stated the staff was wearing the mask around their chin and not around their nose or mouth. Based on credible witness statement, this allegation is deemed Substantiated at this time.

The facility failed to protect the personal rights of residents in care to be able to receive safe and healthful accommodations, in that the facility staff failed to wear face coverings properly while providing care and supervision to residents in care. This is a violation of official government orders requiring the wearing of face coverings while working under specified conditions.

Administrator refused to participate in exit interview. Administrator refused to sign the report. Deficiency cited, copy of report and appeal rights emailed to Licensee/Administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20220309160335
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: YELLOW ROSE ASSISTED LIVING
FACILITY NUMBER: 405850002
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/16/2022
Section Cited
CCR
87468.1
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87468.1 Personal Rights of Residents in All Facilities...To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by
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Administrator will immediately notify all staff to wear masks at all times in the facility. Administrator will hold training with all staff about proper mask-wearing and COVID-19 prevention protocol, and provide training records to CCL by 3/17/2022.
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Based on credible witness observation, the licensee did not ensure staff were wearing face masks in the facility, which poses an immediate health, safety and personal rights risk to residents 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.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022
LIC9099 (FAS) - (06/04)
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