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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 02:29:24 PM
Document Has Been Signed on
11/21/2023 02:29 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:
11/21/2023
TYPE OF VISIT:
Case Management - Annual Continuation
UNANNOUNCED
TIME BEGAN:
02:23 PM
MET WITH:
Administrator Evelyn Strampe
TIME COMPLETED:
02:24 PM
NARRATIVE
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CONTINUED fron 11/21/2023 to compete inspection.
SUPERVISOR'S NAME:
Kelly Burley
TELEPHONE:
(805) 562-0413
LICENSING EVALUATOR NAME:
Mark Jeffries
TELEPHONE:
(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)
Page:
1
of
2
Document Has Been Signed on
11/21/2023 02:29 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:
11/21/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(4)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
11/22/2023
Plan of Correction
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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 Burley
TELEPHONE:
(805) 562-0413
LICENSING EVALUATOR NAME:
Mark Jeffries
TELEPHONE:
(805)562-0400
LICENSING EVALUATOR SIGNATURE:
DATE:
11/21/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/21/2023
LIC809
(FAS) - (06/04)
Page:
2
of
2