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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405801800
Report Date: 06/25/2021
Date Signed: 06/25/2021 02:33:18 PM

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:VALLEY VISTA RESIDENTIAL CAREFACILITY NUMBER:
405801800
ADMINISTRATOR:EVELYN S STRAMPEFACILITY TYPE:
740
ADDRESS:1095 SAN ADRIANO STREETTELEPHONE:
(805) 439-4120
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93405
CAPACITY:6CENSUS: 1DATE:
06/25/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:22 AM
MET WITH:Evelyn S Strampe/AdministratorTIME COMPLETED:
03:00 PM
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At 8:19am, Licensing Program Analyst (LPA) Mark Jeffries arrived at the facility. Announced who he was and the purpose of the visit as to conduct an Annual, Infection Control inspection. LPA explained that he will also conduct a case management visit on the safeguarding of confidential records and investigation interview and issue final findings on the open complaint to this facility.
At 10:38am LPA and Administrator conducted a tour of the physical plant of the facility. LPA observed contracted painters painting the outside of the facility. LPA observed more than two days of perishable and more than seven days of nonperishable foods. At 10:47pm LPA tested water in the single bathroom in the hallway, water temperature tested at 119.1* degrees. LPA observed all rooms had regulated storage, linin and were all in compliance with regulations. LPA observed a locked medication cabinet in the dining room area. LPA observed a locked file draws for record keeping in the living room area. LPA did not observe anything to indicate regulation violations during this facility physical plant tour. At 11:28pm Staff 1 (S1), Administrator and LPA conducted the Infection Control module of the annual inspection tool. LPA did not find any deficiencies at this time. Two different reports were generated on this visit, LPA did cite Regulation 87506(c)(1) on a case management visit related to a complaint that final findings were issued also on this visit.

Exit interview, Report emailed.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021
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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