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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405801800
Report Date: 08/05/2024
Date Signed: 08/05/2024 12:18:08 PM

Document Has Been Signed on 08/05/2024 12:18 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:VALLEY VISTA RESIDENTIAL CAREFACILITY NUMBER:
405801800
ADMINISTRATOR/
DIRECTOR:
EVELYN S STRAMPEFACILITY TYPE:
740
ADDRESS:1095 SAN ADRIANO STREETTELEPHONE:
(805) 439-0478
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93405
CAPACITY: 6CENSUS: 3DATE:
08/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:Administrator, Nellie Corrles TIME VISIT/
INSPECTION COMPLETED:
01:21 PM
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At 10:00am on 08/05/2024, Licensing Program Analyst (LPA) Jeffries arrived at the facility unannounced to conduct the annual facility inspection. LPA met with administrator Nellie Corrals, announced who he was and the reason for the visit.

Administrator and LPA conducted a physical tour of the facility. LPA noted that there is a carbon monoxide detector, smoke detectors,and fire extinguisher present and all functioning within regulation requirements. LPA noted that there is an older alarm/smoke detector system located in the facility. Administrator will have expert contractor to assess the need of secondary alarm/smoke detectors functionality and review if they can operate or need it to be removed. LPA noted that all hallways and doors are free from obstruction and no hazards were noted. LPA noted that there are 4 bedrooms and 2 bathrooms. 3 bedrooms are double occupancy rooms and one is large bedroom is currently single occupancy. LPA noted that all residents bedrooms meet all regulation requirements. LPA noted that the shared bathrooms meet all regulation requirements. LPA observed at least two days of perishable foods and seven days of non-perishable foods on hand at the facility. LPA noted that the facility is clean and in good repair. LPA noted that there is a fenced front patio with table and umbrella for shade as well as a back patio with pergola for shade. LPA noted that all files and medication are located in a locked cabinet in the dinning room area. LPA conducted a staff file review, and resident file review. LPA conducted a sample medication audit which reviewed the Centrally Stored Medication Records (CSMR) for all residents currently in care.

Licensee and LPA conducted a full review of the annual care tools. LPA noted that facility agreed to conduct a facility emergency drill in the next 24 hours and document that drill for each shift. LPA noted that there were no citations issued from the annual care tools and no violations or citations issued as a result of the annual facility physical walk through tour. There are no citation for this annual inspection. One staff and one resident interviewed.

Exit interview, report read, and report provided.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE: DATE: 08/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/05/2024
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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