405850002-10-5-2023-29-AS-KBUY-CX5KJJ-20231031075650

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405850002
Report Date: 10/05/2023
Date Signed: 10/05/2023 02:20:17 PM

Unsubstantiated

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
10/04/2023 and conducted by Evaluator Mark Jeffries

COMPLAINT CONTROL NUMBER: 29-AS-20231004120009

FACILITY NAME:	YELLOW ROSE ASSISTED LIVING		FACILITY NUMBER:	405850002
ADMINISTRATOR:	TESFAZGY, ABIY		FACILITY TYPE:	740
ADDRESS:	4225 CAMP 8 RD		TELEPHONE:	(805) 286-8477
CITY:	PASO ROBLES	STATE: CA	ZIP CODE:	93446
CAPACITY:	15	CENSUS: 9	DATE:	10/05/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Licensee / Abiy Tesfazgy		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff does not ensure that facility has an adequate supply of fresh fruit.

INVESTIGATION FINDINGS:

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At 10:10am on 10/05/2023, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to conduct the initial investigation visit to the allegation to this complaint. LPA met with Licensee Abiy Tesfazgy, announced who he is and the reason for the visit. LPA additionally conducted the annual inspection of the facility on this visit on a separate report.
At 10:30am on 10/05/2023, Licensee and LPA conducted a cursory tour of the facility, focused on the kitchen, pantry, and outside storage shed. LPA observed 2 dozen tangerines, 15 bananas, 5 apples, there was ample supply of fresh vegetables, and meats that were refrigerated. LPA observed at least 2 days supply of perishable foods on hand during this cursory tour of the facility. LPA interviewed Staff 1 and Staff 2 (S1, and S2) who stated that the fresh fruit in the facility is stocked daily if needed and at a minimum of every other day. Both S1 and S2 stated that there is always fresh fruit on hand at the facility. LPA interviewed 3 of 9 residents, R1 - 3 stated that this facility has no problems with food supply or variety of foods. R1-3 stated that if they request food or snacks the facility always has provided food and/or snacks at all meal times and whenever they ask for any type of food for alternative to regular meal times. CONTINUED on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20231004120009

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: 10/05/2023

NARRATIVE

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LPA interviewed Licensee, who stated that the grocery shopping for the facility is done regularly, 3 time per week and as needed. Additionally, fruits and vegetables are often purchased on a daily basis to ensure freshness and quality.
As to the allegation of, "Staff does not ensure that facility has an adequate supply of fresh fruit." it was discovered that on approximate date of 10/04/2023, the facility had a low supply of fresh fruit. Licensee stated on 10/05/2023, that supply of fresh fruit (and other perishable and non-perishable foods) was replenished on 10/04/2023, the day of the observed shortage. Licensee stated that on 10/02/2023 was the last time that fresh fruits were purchased (bananas, apples, tangerines, and strawberry's). S1 and S2, interviewed on 10/05/2023 stated the fresh fruit supply is always replenished as soon as it gets low. R1, R2, and R3 stated on 10/05/2023 that they have never had a problems with meals and snack at this facility and feel safe at this facility. LPA observed grocery receipts and collected copies of grocery receipts dated 10/02/2023, and 10/04/2023. Based on interviews, observations, and documentation there is not enough evidence to support the allegation of, " Staff does not ensure that facility has an adequate supply of fresh fruit". and is unsubstantiated at this time.
Licensee and LPA discussed the importance of fresh foods including fresh fruits to have on hand for residents at all times and agreed that fresh fruits will always be on hand at this facility at residents request.

Exit interview, report

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023

LIC9099 (FAS) - (06/04)

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