405850000-10-21-2024-29-AS-MJES-DA9RCP-20241021125441

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405850000
Report Date: 10/21/2024
Date Signed: 10/21/2024 12:55:56 PM

Document Has Been Signed on 10/21/2024 12:55 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 II		FACILITY NUMBER:	405850000
ADMINISTRATOR:	STRAMPE, EVELYN		FACILITY TYPE:	740
ADDRESS:	1712 VICENTE DR		TELEPHONE:	(805) 439-0087
CITY:	SAN LUIS OBISPO	STATE: CA	ZIP CODE:	93405
CAPACITY:	6	CENSUS: 3	DATE:	10/21/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:38 AM
MET WITH:	Administrator, Evelyn Strampe		TIME COMPLETED:	02:09 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 10:15 am on 10/21/2024, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to conduct the annual facility inspection. LPA rang the door bell and knocked on the door from 10:15am to 10:27am, LPA attempted to call Licensee at all of their other facility phone numbers. LPA contacted Licensee sister who is an administrator at a different facility and notified LPA by voice message that Licensee was at Costco and on their way back to the facility. At 10:38am, a visitor of a resident (R1) left out the side gate of the facility then the Licensee drove up to the facility and the caregiver opened the front door to the facility. LPA met with facility Administrator Evelyn Strampe who explained that the visitor that was leaving was visiting their farther who is a new resident at the facility. When LPA interviewed Care Giver (S1), care giver stated that they didn't hear the knocking, door bell, or the phone ringing for over 12 minutes, S1 also stated that they were providing care for R2 at the time that LPA was attempting to gain entrance to the facility, however S1 came to the front door as soon as the Administrator pulled up and LPA noted 3 different variations of reasons why S1 did not answer the facility front door for LPA. LPA interviewed Visitor (V1) who stated S1 did not answer the door because they were scared. LPA Jeffries was wearing CCL ID badge and had identified himself as "Community Care Licensing, Department of Social Services." S1 refused to open facility door until Licensee arrived. This resulted in a citation of Inspection Authority and is cited and noted as part of the care tools module (H&S:1569.32). 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. CONTINUED on LIC9099-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark Jeffries	TELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2024

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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Document Has Been Signed on 10/21/2024 12:55 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 II	FACILITY NUMBER: 405850000
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.32

Regulations

Any duly authorized officer, employee, or agent of the department may, upon presentation of proper identification, enter and inspect any place providing personal care, supervision, and services at any time, with or without advance notice, to secure compliance with, or to prevent a violation of, this chapter. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on S1 denying Properly identified Licensing Program Analyst Jeffries entrance to the facility, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/22/2024
	Plan of Correction
1 2 3 4	Administrator conducts a one hour class with S1 on Residents Rights that include CCL inspection authority training.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark Jeffries	TELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2024

LIC809 (FAS) - (06/04)

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