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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405801800
Report Date: 07/20/2022
Date Signed: 07/21/2022 07:28:23 AM


Document Has Been Signed on 07/21/2022 07:28 AM - 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:VALLEY VISTA RESIDENTIAL CAREFACILITY NUMBER:
405801800
ADMINISTRATOR:EVELYN S STRAMPEFACILITY TYPE:
740
ADDRESS:1095 SAN ADRIANO STREETTELEPHONE:
(805) 439-0478
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93405
CAPACITY:6CENSUS: 3DATE:
07/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:57 AM
MET WITH:Nellie Corrales/Lead Home CaregiverTIME COMPLETED:
03:00 PM
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 At 12:00pm on 07/20/2022, Licensing Program Analyst (LPA) Jeffries arrived at the facility to conduct the annual infection control inspection. LPA was met at door by Nellie Corrales (S1). LPA announced who he was and the reason for the visit. LPA was screened at the door for COVID-19 protocols.

At 12:05pm S1 and LPA conducted a walking tour of the facility. The facility has a front courtyard that is enclosed by a fence. The facility consist of 4 bedrooms, 2 bathrooms, living room and kitchen area and backyard covered patio. The medications are located in a locked cabinet in the dining room area, staff and resident files are locked cabinet in the dining room. LPA observed an ample supply of more than 2 day of perishable and 7 days of non perishable foods. LPA observed a screening station and the single point front entrance and stocked bathrooms with appropriate infection mediation supplies such as hand sanitizer, liquid soap and paper towels. The first restroom in the hallway, towels are on request, due to specific Resident lacking impulse control and lack of hazard awareness. LPA observed fire detectors throughout the facility that are hard wired. LPA did not make any observations during the walking tour of the facility that would put residents in danger at this time.
At 12:45pm S1 and LPA conducted the infection control module of the annual inspection. LPA did not discover any deficiencies during the infection control module. There were no citations or deficiencies issued during this infection control module, annual inspection.

Exit interview, repot singed and report emailed.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2022
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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