405850050-3-6-2026-29-AS-RDLN-DRWV8R-20260306151310

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405850050
Report Date: 03/06/2026
Date Signed: 03/06/2026 03:13:23 PM

Document Has Been Signed on 03/06/2026 03:13 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 RESIDENCE		FACILITY NUMBER:	405850050
ADMINISTRATOR/ DIRECTOR:	GERMAIN, ANDRIANNA		FACILITY TYPE:	740
ADDRESS:	6430 MIRA CIELO		TELEPHONE:	(805) 541-1473
CITY:	SAN LUIS OBISPO	STATE: CA	ZIP CODE:	93401
CAPACITY: 6		CENSUS: 6	DATE:	03/06/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:15 AM
MET WITH:	Rachelle Tellez, Back up Administrator		TIME VISIT/ INSPECTION COMPLETED:	03:13 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) De Leon arrived at 10:15 am to conduct a 1 year annual visit to the facility above. LPA met with Back up Administrator, Rachelle Tellez and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted. The following was inspected and noted during the annual visit: Infection Control: The facility has a current Infection Control Plan. The facility has a sign in and out binder for visitors at entry with hand sanitizer. The bathrooms have toilet paper, paper towels, hand soap, and hand washing signs are visible in the guest bathroom. The facility has EPA approved disinfectants spray and cleaners. The facility has a 30 day supply of PPE. Quarantined or isolated individuals will have meals and medication delivered to rooms. Staff are trained on infection control and the use of Personal Protective Equipment (PPE). Physical Plant & Environment Safety: The fire extinguishers were last charged and inspected on May 13, 2025. The facility has 6 resident bedrooms with bathrooms and 1 guest bathroom. LPA was authorized to enter and inspect facility. The facility dual smoke and carbon monoxide detectors hard wired thorugh out with a sprinkler system. The lighting and lamps are sufficient for the use of the facility and for resident comfort. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The showers have non-skid mats or textured bottoms. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant, cleaning solutions and poisons are inaccessible to residents locked in the laundry room and supply closet. The facility has sufficient space inside and outside for activities, with outside furniture and shaded areas around the backyard. The facility has a secured perimeter with 6 locked gates, automated entry and exiting gates, 1 lock was broken on gate by tennis court. There are 2 large ponds inaccessible to residents in care with a fully fenced perimeter, the pool and spa is completely fenced with a locked gate for entry and exit. The facility has telephone and internet service for resident use. Cont. 809-C

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Rachael De Leon
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/06/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2026

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

LIC809 (FAS) - (06/04)

Page: 1 of 5

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)

Page: 2 of 5

Document Has Been Signed on 03/06/2026 03:13 PM - It Cannot Be Edited

Created By: Rachael De Leon On 03/06/2026 at 02:38 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: 03/06/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(e)(5)

This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 1 outo f 6 gates was unlocked by the tennis court within the secured perimeter which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/13/2026
	Plan of Correction
1 2 3 4	Administrator agreed to have maitnance go around secured perimeter making sure a fencing and gates are in good repair and locked. Train all staff in regulation 87705. Provide an up to date LIC 500.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 03/06/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2026

LIC809 (FAS) - (06/04)

Page: 3 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: EDNA ROSE RESIDENCE	FACILITY NUMBER: 405850050
	VISIT DATE: 03/06/2026

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Operational Requirements: The facility has a current plan of operation on file with the department. The Facility is operating in compliance with the granted fire clearance. The facility has current liability insurance and expires on 4/29/2026. The facility is approved for a capacity of 6. The fire clearance is granted for 6 Non-Ambulatory 2 of which may be bedridden. Hospice is approved for 6.
Staffing: The facility currently employes 4 full time staff, 5 part time staff and 2 Administrators. Staff records are kept confidential. Files reviewed had current 1st Aid/CPR, Personnel Records/Application, Health screening with TB results, Criminal Record statements, and Fingerprint clearance and education requirements. Administrator Certificate expires March 22, 2024.
Personnel Records & Training: The facility keeps confidential files for each staff member. Five Staff files were reviewed on Relias training completed for all subjects/topics and hours for 2025-2026.
Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Facility does submit incident reports to the department when required. LPA reviewed 5 resident files for signed Admission Agreements, Personal Rights, Safeguard for property and valuables, LIC. 602A Physicians report, Appraisals Needs and Services Plan, Emergency and ID forms, all forms were legible and records are kept confidential.
Food Service: The facility handles and prepares food safely. The facility has 2-day perishables and 7-day non-perishables and plenty extra, to meet the food service requirement. The freezer is kept at 0 degrees and the refrigeration is kept at 40 degrees or lower. All food is covered, stored and marked appropriately. Food, snacks and drinks are available when the residents want them. Cleaning solutions and equipment are stored separately from food supplies. Kitchen staff are observed for personal hygiene and food sanitation practices. Incidental Medical Services: Facility provides assistance in arranging transportation to medical and dental appointments when needed. Residents have on-call Doctor that visits facility. The facility uses the Medication Administration Record (MAR) along with the Centrally Stored Medication and Destruct Records (CSMDR). LPA reviewed residents’ medications, no labels were altered, no medications were expired and all medications were kept in their original containers.
Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts quarterly disaster drills. Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full facility in an emergency.
Residents with Special Health Needs: The facility does accept dementia residents in care. The facility uses Hospice and Home Health Services plan are kept current and up to date. The facility does not have delayed egress. The facility does have a secured perimeter with fencing and 6 locked gates. The facility does have exiting door alarms. Continued 809-C

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Rachael De Leon
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/06/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2026

LIC809 (FAS) - (06/04)

Page: 4 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: EDNA ROSE RESIDENCE	FACILITY NUMBER: 405850050
	VISIT DATE: 03/06/2026

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	LPA interviewed 2 staff and 2 residents. Exit interview conducted, deficiency cited, 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: 03/06/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2026

LIC809 (FAS) - (06/04)

Page: 5 of 5