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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850050
Report Date: 03/02/2022
Date Signed: 03/02/2022 04:10:33 PM

Document Has Been Signed on 03/02/2022 04:10 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:EDNA ROSE RESIDENCEFACILITY NUMBER:
405850050
ADMINISTRATOR:SOO, ZOLTANFACILITY TYPE:
740
ADDRESS:6430 MIRA CIELOTELEPHONE:
(805) 541-1473
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93401
CAPACITY: 6CENSUS: 6DATE:
03/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:52 PM
MET WITH:Jessica Bailey, AdministratorTIME COMPLETED:
03:10 PM
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On 3/02/22 at 1:52 pm, Licensing Program Analyst (LPA) Chavez conducted an unannounced on-site annual infection control visit to the facility above. LPA met with Administrator Jessica Bailey and explained the purpose of the visit.

LPA toured the facility with Floor Manager Victoria Vargas and observed the following: The facility has signage at the front door regarding the visitor policy. LPA was screened upon entry. Each resident room includes an attached bathroom. Individual resident bathrooms and the bathroom in the common area were stocked with soap and paper towels. The facility has signage for COVID infection control measures including cough etiquette and handwashing reminders. LPA observed all staff wearing surgical masks properly. Fire extinguishers, located in the downstairs hall and upstairs hall, are fully charged and were inspected on 5/06/2021.

At 2:37 pm, LPA conducted the Infection Control mitigation module with the administrator. No deficiencies cited.

Exit interview conducted and report emailed to the administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE: DATE: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/02/2022
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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