<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850000
Report Date: 10/06/2022
Date Signed: 10/07/2022 07:58:58 AM


Document Has Been Signed on 10/07/2022 07:58 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 CARE IIFACILITY NUMBER:
405850000
ADMINISTRATOR:STRAMPE, EVELYNFACILITY TYPE:
740
ADDRESS:1712 VICENTE DRTELEPHONE:
(805) 439-0087
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93405
CAPACITY:6CENSUS: 3DATE:
10/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:32 PM
MET WITH:Evelyn Strampe/AdministratorTIME COMPLETED:
02:35 PM
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
 At 12:37pm on 10/06/2022, Licensing Program Analyst (LPA) Jeffries conducted an unannounced infection control annual inspection visit. LPA was screened at the door by staff for COVID-19 protocols. LPA met with Administrator Eveylyn Starmpe and announced who he was and the reason for the visit.

At 1:00pm Administrator and LPA conduced a cursory tour of the facility. This facility is a 3 bedroom and 3 bathroom, two living rooms, kitchen and dining room with a courtyard in the back with shade for residents. The medications are stored in a locked cabinet in the kitchen area, LPA observed liquid soap and paper towels in each of the three bathrooms. LPA observed a 30 day supply of PPE and noted that this Administrator has several facility's with additional PPE supplies for all the facilities owned by this administrator, LPA observed more than a two day supply of perishables and at least a seven day supply of nonperishable foods. LPA observed four different fire extinguishers to be in the green range. LPA observed the carbon monoxide detector to be working and functioning correctly by testing. LPA observed the facility to be clean and in good repair, LPA did not observed anything in this cursory facility tour that would be harmful to residents in care on this visit.
At 1:45pm Administrator and LPA conducted the infection control module portion of the annual infection control inspection. LPA noted one technical advisory pertaining to the postings of CCLD PINs and PIN summaries. Administrator agreed to print up CCLD PINs and post them in a readily accessible location by the end of this day 10/06/2022. One technical violation assessed, no other citations issued on this infection control annual inspection.

Exit interview, report signed, and report emailed.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:
DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2022
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 2