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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850000
Report Date: 11/21/2023
Date Signed: 11/21/2023 02:21:51 PM


Document Has Been Signed on 11/21/2023 02:21 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 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:
11/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator Evelyn StrampeTIME COMPLETED:
01:33 PM
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 At 10:00am on 11/21/2023, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to conduct the annual facility inspection. LPA met with facility Administrator Evelyn Strampe announced who he is and the reason for the visit.

Administrator and LPA conduced a full tour of the facility inside and outside.. 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. Currently there are 3 resident all in single occupancy rooms. The medications are stored in a locked cabinet in the kitchen area as well as the first aide kit with all required items, LPA observed at least two days of perishable foods and at least seven days of non perishable foods on hand at the facility. LPA observed working smoke detectors throughout the facility and a working carbon monoxide detector between the living room and dining room. There is a charged in green fire extinguisher and the halls, exits and pathways in the facility are free and clear of debris. LPA conducted a staff rerecords, resident records, and medication audit and found Resident 1 and 2 (R1 and R2) to have current Centrally Stored Medication Records (CSMR), R3 did not have a current CSMR and that citation was addressed in the care tools module below. licensee to update R3's CSMR within 24 hours of this report and provide proof to LPA by text or email. LPA noted that the facility was clean and in good repair. LPA noted that there were no other violations or citation issued as a result of the facility walk through.

Administrator and LPA conducted a full review of the annual care tools modules. LPA noted that only one citation was issued from the care tools module pertaining to R3's CSMR. LPA noted that no other technical, violation, or citation was issued as a result of the full review of the annual care tools module. One type A citation issued as a result of this annual inspection.

Exit interview, citation issued, report read, report and appeal rights provided.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2023
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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