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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405801800
Report Date: 07/24/2023
Date Signed: 07/24/2023 03:36:54 PM


Document Has Been Signed on 07/24/2023 03:36 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:EVELYN S STRAMPEFACILITY TYPE:
740
ADDRESS:1095 SAN ADRIANO STREETTELEPHONE:
(805) 439-0478
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93405
CAPACITY:6CENSUS: 2DATE:
07/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Nellie Corrals / AdministratorTIME COMPLETED:
03:35 PM
NARRATIVE
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 At 10:00am on 07/24/2023, 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 are fire detectors, carbon monoxide detector, and fire extinguisher present and all functioning within regulation requirements. 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 a staff bedroom. 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 could not conduct a accurate medication audit due to missing information from the Centrally Stored Medication Record which will be addressed in the Care Tool Modules and stated below.

At 11:00am, Administrator and LPA conducted the Care Tools Modules review. LPA noted the following: Administrator required CPR renewal as currently working staff, which is a citation; Administrator needs additional 8 hours of continuing training for recertification renewal of Administrators Certificate, which is a citation; Medication information missing on Centrally Stored Medication Record, which is a citation; Quartlery drills not documented, which is a Technical Violation (TV) at this time. Administrator and LPA discussed the Plan of Corrections (POC) to all of the citations and TV's issued on this annual inspection. LPA will follow up on all POC's until facility compliance is met.

Exit interview, report read, report singed, appeal rights report provided.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2023
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 5


Document Has Been Signed on 07/24/2023 03:36 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored:

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 in 2 out of 2 medications of Resident JC which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2023
Plan of Correction
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Completed Centtrally Stored Medication Records by 07/25/2023 and provided copy to LPA.
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.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5


Document Has Been Signed on 07/24/2023 03:36 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

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 in one out of 1 staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2023
Plan of Correction
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Administrator will take CPR on Relise Accademy in the next 24 hours and provied LPA with proof.
Type B
Section Cited
CCR
87412(a)(6)(A)
Personnel Records
(A) For administrators this shall include verification that he/she meets the educational requirements in Section 87405(d) through (g).

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 in 8 out of of 20 hours of continued training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/07/2023
Plan of Correction
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Adminsitrator will have 8 hours of continuing training completed by 08/07/2023 and will update LPA on recirtification status of Adminstrators cirtificate.
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 BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5