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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405801800
Report Date: 06/25/2021
Date Signed: 06/28/2021 07:29:00 AM



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
06/03/2021 and conducted by Evaluator Mark Jeffries
COMPLAINT CONTROL NUMBER: 29-AS-20210603145421
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
UNANNOUNCEDTIME BEGAN:
11:23 AM
MET WITH:Evelyn S Strampe/AdministratorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Due to a lack of supervision, resident sustained a head injury while in care.

Facility staff failed to meet the needs of the resident.
INVESTIGATION FINDINGS:
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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 investigation interview and issue final findings on the complaint to the allegations listed above, LPA will also conduct a case management visit on the safeguarding of confidential records and conduct an Annual Infection Control Inspection.

As to the allegation of, "Due to the lack of supervision, resident sustained a head injury while in care." Based on documentation and interviews the investigation discovered that Staff 1 (S1) and Staff 2 (S2) helped Resident 1(R1)with dinner at approximately 6:00pm. After R1 was finished with dinner S1 helped R1 to bedroom and laid R1 down on bed; approximately 5-10 minutes later S1 and S2 heard a "thud" from R1's room. R1 had fell in their room at approximately 6:15pm on 05/25/2021. S1 accessed R1 and called 911, R1's emergency contact (EC) and administrator. Emergency Responders (EMTs) arrived, took R1s vitals and made telephone contact with R1's EC while at the facility.
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 29-AS-20210603145421
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: VALLEY VISTA RESIDENTIAL CARE
FACILITY NUMBER: 405801800
VISIT DATE: 06/25/2021
NARRATIVE
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It was determined by EMTs and EC that R1 did not need to go to the hospital. S1 asked EMTs about dressing the wound on the back of R1's head. S1 stated the EMT told S1 that dressing the wound was S1s job. EMTs left the facility at approximately 7:00pm. S1 dressed the wound on the back of R1;s head, S1 left the door to R1's room open and checked R1's condition at 11:00pm, S1 stated that R1's response was :good and responsive". S1 assisted R1 with urination at 1:00am and 3:00am at the request of R1. S1 conducted a check on R1 for breakfast, R1 'grunted' at S1. At 10:00am EC for R1 arrived at the facility for a visit. EC stated that R1 was not very responsive but was moving arms and grunting but pupils would not dilate. EC instructed S1, to call if R1's condition worsened or change. S1 checked on R1 at 12:00pm, R1 was responding with grunting and resisted getting up, but no change from the morning check. S1 stated that they left R1s door open and monitored throughout the day. At 6:00pm S1 checked on R1, S1 stated R1s lips were dry so S1 swabbed R1's lips to help with hydration. At 7:00pm S1 swabbed R1s lips with noodle soup broth. At 11:00pm R1 noticed S1 was drooling, S1 then called EC, 911 and administrator. R1 was transported to hospital when EMTs arrived. Based on the interviews there is no evidence to support the allegation of, "Due to a lack of supervision, resident sustained a head injury while in care." therefore, the allegation is unsubstantiated at this time.

As to the allegation of, "Facility staff failed to meet the needs of the resident."It was determined through interviews and observation that S1 had swabbed R1's lips with water at 6:00pm on 05/26/2021 due to R1's lips appearing dehydrated and not eating throughout this day. At 7:00pm S1 swabbed R1's lips with a noodle soup broth. S1 showed the ingredients of the soup to LPA on 06/10/2021. During the interview LPA noted that S1's pronunciation of "soup" sounds like "soap". LPA asked S1 to pronounce soup four times, all four pronunciations sounded like "soap" to the LPA. LPA asked if S1 had fed soap to R1, S1 stated, "of course not, I feed him soup. LPA did not discover any evidence that R1's needs were failed to be met. " Based on the interviews and LPA observation, the allegation of, "Facility staff failed to meet the needs of the resident." is unsubstantiated at this time.

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
LIC9099 (FAS) - (06/04)
Page: 2 of 2