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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850050
Report Date: 02/16/2023
Date Signed: 02/16/2023 06:34:42 PM

Document Has Been Signed on 02/16/2023 06:34 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: 5DATE:
02/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:25 PM
MET WITH:Rachelle Tellez, AdministratorTIME COMPLETED:
06:45 PM
NARRATIVE
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On 2/16/23 at 4:25 pm, Licensing Program Analyst (LPA) Chavez conducted an unannounced on-site annual infection control visit to the facility above. LPA met with Staff #1 (S1), and explained the purpose of the visit. At 5:00 pm, Rachelle Tellez, Administrator, arrived, and LPA explained the purpose of the visit.

LPA toured the facility with S1 until 5:00 pm and the administrator after 5:00 pm and observed the following: The facility has signage at the front door regarding the visitor policy. LPA was screened upon entry. The facility has signage for COVID infection control measures including cough etiquette and handwashing reminders. LPA observed all staff wearing masks. There are six single-occupancy resident rooms. Each resident room includes an attached bathroom and there is an additional resident bathroom in the downstairs hall. Bathrooms were stocked with soap and paper towels. Between 4:50 pm and 5:21 pm, water temperatures in four of the resident bathrooms were recorded at 131.7F, 124.3F, 151.8F, and 132.1F degrees. Water temperatures are not in compliance of the regulatory 105F to 120F degrees. Deficiency cited. Fire extinguishers (4), located in the entryway cabinet, downstairs hall, upstairs hall, and kitchen are fully charged and were inspected on 5/25/22.

At 5:30 pm, LPA conducted the Infection Control mitigation module with the administrator.

Exit interview conducted, deficiency cited and the report and appeal rights given to the administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2023
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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Document Has Been Signed on 02/16/2023 06:34 PM - It Cannot Be Edited


Created By: Darlene Chavez On 02/16/2023 at 06:04 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: EDNA ROSE RESIDENCE
FACILITY NUMBER: 405850050

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
87303(e)(2) Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement was not met as evidenced by:
Deficient Practice Statement
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Based on testing, the licensee did not comply with the section cited above in four bathrooms whose water temperatures were recorded between 124.3F and 151.8F degrees which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/17/2023
Plan of Correction
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Licensee will adjust the water temperatures to comply with the regulation, take videos of each bathroom not in compliance and send videos to LPA by end of day 2/17/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Kelly Burley
LICENSING EVALUATOR NAME:Darlene Chavez
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2023


LIC809 (FAS) - (06/04)
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