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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405801800
Report Date: 07/21/2026
Date Signed: 07/21/2026 03:09:56 PM

Document Has Been Signed on 07/21/2026 03:09 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:VALLEY VISTA RESIDENTIAL CAREFACILITY NUMBER:
405801800
ADMINISTRATOR/
DIRECTOR:		NELLIE CORRALESFACILITY TYPE:
740
ADDRESS:1095 SAN ADRIANO STREETTELEPHONE:
(805) 439-0478
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93405
CAPACITY: 6CENSUS: 1DATE:
07/21/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Administrator - Nellie CorralesTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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At 8:40am, on 7/21/2026, Licensing Program Analyst (LPA) Haner-Tomasko arrived at the facility unannounced to conduct the annual facility inspection. LPA met with Administrator Nellie Corrales, announced who he was and the reason for the visit.

Administrator and LPA conducted a full tour of the facility. This facility is a single story residential home with four bedrooms (three for residents and one for staff), there is a shared full bathroom in the hallway and one full bathroom en-suite to bedroom #1. There is a living room, dining area, and kitchen. Access to the laundry area and garage is through a locked door for resident safety.

Upon arriving LPA observed the Administrator had just arrived, they walked into the facility together and the other staff member present was sitting on a couch in the living room. At 8:56am LPA observed the knife drawer unlocked with approximately ten (10) knives varying in size. The cabinet under the kitchen sink unlocked containing various chemicals (soft scrub, dishwashing pods, 409). Two bottles of liquid lorazepam in the kitchen refrigerator not locked up. Kitchen cabinets had debris and grease on the shelves inside and a drawer under the oven containing baking pans with dark colored liquid on them. A cabinet in the dining room containing staff medication unlocked as well as diabetic supplies (including lancets) and a partially filled sharps container sitting on top of the dining room cabinets. At 9:05am in the hallway shared bathroom in the medicine cabinet various staff cosmetic items including hair dye products. In resident bedroom #4 across from the bathroom a bottle of Pledge sitting on top of a night stand and three bottles of athlete foot spray in the closet. A bottle of spray Lysol in the top of the dual linen cabinets located between bedrooms #2 and #3. All of the items listed above were left unattended and accessible.
(Continued on LIC809-C)
Kelly Burley
Garrett Haner-Tomasko
DATE: 07/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/21/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 31
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 07/21/2026 03:09 PM - It Cannot Be Edited


Created By: Garrett Haner-Tomasko On 07/21/2026 at 10:13 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VALLEY VISTA RESIDENTIAL CARE
FACILITY NUMBER: 405801800

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(6)(A-F)
(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: (A) The name of the resident for whom prescribed. (B) The name of the prescribing physician. (C) The drug name, strength and quantity. (D) The date filled. (E) The prescription number and the name of the issuing pharmacy. (F) Instructions, if any, regarding control and custody of the medication.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above when Resident #1's (R1's) medications were not centrally stored which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/18/2026
Plan of Correction
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Administrator completed the CSMDRs for R1 during LPA visit. Administrator states they will submit updated CSMDRs to LPA vis email on 8/18/2026.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kelly Burley
NAME OF LICENSING PROGRAM MANAGER:
Garrett Haner-Tomasko
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/21/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2026


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: VALLEY VISTA RESIDENTIAL CARE
FACILITY NUMBER: 405801800
VISIT DATE: 07/21/2026
NARRATIVE
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LPA noted that the backyard and the front yard both have seating and shade for residents and visitors. The facility has wired smoke detectors in each bedroom and hallway leading to bedrooms that are all working, the carbon monoxide detector is in the hallway and functioning normally. LPA observed a fire extinguisher near the kitchen that was in the green compression range, purchased on 7/21/2026. LPA tested facility hot water at 105.8°F, within regulation temperatures 105-120°F. LPA observed at least 2-days of perishable and at least 7-days of nonperishable foods. LPA noted that the facility has no obstructions in hallways, doorways or exits.

Medications are locked in a cabinet in the kitchen area. LPA attempted to conducted a medication audit, noting the facility did not have Centrally Stored Medication and Destruction Records for the one resident in care. LPA reviewed the medication expiration dates. During staff record review the Administrator could not provide documentation of annual training for three of three staff and was also not able to provide documented training of annual medication training for themself as the only staff that provides assistance with self-administration of medications. LPA review of resident file records revealed one of one residents did not have a pre-placement appraisal or reappraisal. Administrator also could not provide LPA documentation of quarterly emergency drills and stated the last drill conducted at the facility was in November 2025.

During a visit conducted on 1/21/2026 this facility was issued a Notice of Operation in Violation of Law (NOVL). On 2/25/2026, Community Care Licensing received an application and as of today's visit LPA noted the application is in process.

LPA and Administrator conducted a review of the annual care tool modules.

Exit interview, deficiencies cited on LIC9099-D pages, two civil penalties in the amount of $250 for repeat violations within twelve months are being assessed on the attached LIC421FCs, report signed, report and appeal rights provided to the Administrator.
NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Garrett Haner-Tomasko
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2026
LIC809 (FAS) - (06/04)
Page: 5 of 31
Document Has Been Signed on 07/21/2026 03:09 PM - It Cannot Be Edited


Created By: Garrett Haner-Tomasko On 07/21/2026 at 01:50 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VALLEY VISTA RESIDENTIAL CARE
FACILITY NUMBER: 405801800

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above when they left knives and hazardous items unattended and unlocked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/22/2026
Plan of Correction
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Administrator locked the items up upon finding them. They will also conduct training along with staff on the importance of keeping hazardous items locked and inaccessible and email the LPA training certificates on or before 8/4/2026.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kelly Burley
NAME OF LICENSING PROGRAM MANAGER:
Garrett Haner-Tomasko
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/21/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2026


LIC809 (FAS) - (06/04)
Page: 6 of 31
Document Has Been Signed on 07/21/2026 03:09 PM - It Cannot Be Edited


Created By: Garrett Haner-Tomasko On 07/21/2026 at 01:50 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VALLEY VISTA RESIDENTIAL CARE
FACILITY NUMBER: 405801800

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above when three of three staff have not had annual training in the last year which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/18/2026
Plan of Correction
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Administrator states they will ensure all staff are trained and submit proof of training to LPA on or before 8/18/2026.
Type B
Section Cited
HSC
1569.69(b)
Other Provisions
(b) Each employee who received training and passed the examination required in paragraph (5) of subdivision (a), and who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above when the Administrator as the only staff who assists with self-administration of medications has not completed annual training in the last year which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/18/2026
Plan of Correction
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Administrator states they take training to meet this regulation and submit proof of training to LPA on or before 8/18/2026.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kelly Burley
NAME OF LICENSING PROGRAM MANAGER:
Garrett Haner-Tomasko
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/21/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2026


LIC809 (FAS) - (06/04)
Page: 7 of 31
Document Has Been Signed on 07/21/2026 03:09 PM - It Cannot Be Edited


Created By: Garrett Haner-Tomasko On 07/21/2026 at 01:50 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VALLEY VISTA RESIDENTIAL CARE
FACILITY NUMBER: 405801800

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(29)
General Food Service Requirements
(29) All equipment, fixed or mobile, and dishes, shall be kept clean and maintained in good repair and free of breaks, open seams, cracks or chips.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above when dirty baking dishes were stored which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/04/2026
Plan of Correction
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Administrator states they will clean the dishes and drawer they are stored in and email LPA photos of the dishes and drawer on or before 8/4/2026.
Type B
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above when two bottles of lorazepam were left unlocked and accessible in the kitchen refrigerator which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/04/2026
Plan of Correction
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Administrator moved the bottles to the garage refrigerator and states they will purchase a lock box for the refrigerated medications to be stored in the kitchen refrigerator. They will email LPA a photo of the lock box on or before 8/4/2026
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kelly Burley
NAME OF LICENSING PROGRAM MANAGER:
Garrett Haner-Tomasko
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/21/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2026


LIC809 (FAS) - (06/04)
Page: 8 of 31
Document Has Been Signed on 07/21/2026 03:09 PM - It Cannot Be Edited


Created By: Garrett Haner-Tomasko On 07/21/2026 at 01:50 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VALLEY VISTA RESIDENTIAL CARE
FACILITY NUMBER: 405801800

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on interview, and record review, the licensee did not comply with the section cited above when one of one resident records do not contain a pre-admission appraisal or a reappraisal which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/04/2026
Plan of Correction
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Administrator states they will create a reappraisal for R1 and email it to the LPA on or before 8/4/202
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above when which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/04/2026
Plan of Correction
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Administrator states they will conduct a drill and a document to record drills conducted throughout the year and email the document and details of the drill conducted to the LPA on or before 8/4/2026.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kelly Burley
NAME OF LICENSING PROGRAM MANAGER:
Garrett Haner-Tomasko
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/21/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2026


LIC809 (FAS) - (06/04)
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