405801800-2-16-2022-29-AS-KBUY-CC7V94-20220304151342

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405801800
Report Date: 02/16/2022
Date Signed: 02/16/2022 06:48:03 PM

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
02/11/2022 and conducted by Evaluator Jeannette Olson

COMPLAINT CONTROL NUMBER: 29-AS-20220211152718

FACILITY NAME:	VALLEY VISTA RESIDENTIAL CARE		FACILITY NUMBER:	405801800
ADMINISTRATOR:	EVELYN S STRAMPE		FACILITY TYPE:	740
ADDRESS:	1095 SAN ADRIANO STREET		TELEPHONE:	(805) 439-0478
CITY:	SAN LUIS OBISPO	STATE: CA	ZIP CODE:	93405
CAPACITY:	6	CENSUS: 4	DATE:	02/16/2022
		UNANNOUNCED	TIME BEGAN:	04:05 PM
MET WITH:	Nellie Corrales, Administrator		TIME COMPLETED:	05:10 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff are not wearing face masks

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Olson conducted an unannounced 10-day complaint investigation visit to the facility above. LPA met with Nellie Corrales, Administrator, and explained the purpose of the visit.

LPA entered the facility at 4:10 PM and observed administrator not wearing a mask. After opening the door LPA announced that she was from Licensing and administrator immediately went nearby to the living room where the mask was and put it on. Administrator stated sometimes they don’t wear a mask because they are eating and drinking between helping residents. At around 4:25 PM LPA noticed Staff (S1) in the dining room with mask on.

Continued on 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2022

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 3

Control Number 29-AS-20220211152718

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: 02/16/2022

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 Administrator and resident (R1) regarding the allegation. Administrator interview revealed that staff often wear masks in the facility. Residents 1 (R1) interview stated the staff wear masks most of the time when helping them in the facility. A credible witness (W1) stated on 2/10/2022, W1 observed two staff in the living room who were not wearing masks. W1 stated the staff did not have masks nearby them or around their necks, and had to get up to go find them. Based on LPA observation and the credible witness statement this allegation is deemed Substantiated at this time.

The facility failed to protect the personal rights of residents in care to be able to receive safe and healthful accommodations, in that the facility staff failed to wear face coverings properly while providing care and supervision to residents in care. This is a violation of official government orders requiring the wearing of face coverings while working under specified conditions.

Exit interview conducted, deficiency cited, copy of report and appeal rights emailed to Licensee/Administrator.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 29-AS-20220211152718

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/16/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/16/2022 Section Cited CCR 87468.1	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities ...To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator has agreed to immediately notify all staff to wear masks at all times in the facility. Administrator agreed to hold training with all staff about proper mask-wearing and COVID-19 prevention protocol, and provide training records to CCL by 2/23/2022.
	8 9 10 11 12 13 14	Based on credible witness and LPA observation, the licensee did not ensure staff were wearing face masks in the facility, which poses an immediate health, safety and personal rights risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 3