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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850047
Report Date: 01/31/2022
Date Signed: 01/31/2022 03:42:19 PM

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 IIIFACILITY NUMBER:
405850047
ADMINISTRATOR:CORRALES, NELLIE SFACILITY TYPE:
740
ADDRESS:1557 GALLEON WAYTELEPHONE:
(805) 439-4120
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93405
CAPACITY:6CENSUS: 5DATE:
01/31/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Evelyn Strampe, LicenseeTIME COMPLETED:
01:40 PM
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At 11:50 am, on 1/31/2022, Licensing Program Analyst (LPA) Darlene Chavez conducted an unannounced annual infection control inspection of the facility above. LPA met with Evelyn Strampe, Licensee and explained the reason for the visit. LPA and Licensee toured the facility.

LPA’s initial tour of the facility resulted in observations which were immediately corrected. LPA was screened upon entry to the facility by staff. Licensee has agreed to ensure all staff are fit tested for N95 respirators and provide a certification and staff sign-in sheet. At 12:05 pm, LPA observed the fire extinguisher in the laundry room which has not been inspected. Licensee will ensure fire extinguisher is inspected or purchase a new one and send a photo of receipt to LPA. Between 12:03 pm and 1:03 pm, the kitchen water temperature was recorded at 120 F, bathroom #1 at 118.1, and bathroom #2 at 117.4 F. At 12:12 pm, LPA observed outside gate which does not spring closed. Licensee will repair gate so that there is an automatic closing mechanism. Licensee will send a video of the repaired gate.

At 12:30 pm, LPA conducted the Infection Control mitigation module with the licensee.

Exit interview conducted and report emailed to the licensee.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2022
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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