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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850047
Report Date: 05/13/2026
Date Signed: 05/13/2026 01:36:01 PM

Document Has Been Signed on 05/13/2026 01:36 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:VALLEY VISTA RESIDENTIAL CARE IIIFACILITY NUMBER:
405850047
ADMINISTRATOR/
DIRECTOR:		EVELYN STRAMPEFACILITY TYPE:
740
ADDRESS:1557 GALLEON WAYTELEPHONE:
(805) 439-4120
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93405
CAPACITY: 6CENSUS: 5DATE:
05/13/2026
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Licensee/Administrator-Evelyn StrampeTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
NARRATIVE
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At 9:00am, on 5/13/2026, Licensing Program Analyst (LPA) Haner-Tomasko arrived at the facility unannounced to conduct a Case Management - Other visit. LPA met with Licensee/Administrator Evelyn Strampe, announced who he was and the reason for the visit.

During today's visit LPA and Administrator toured the facility and LPA checked the well-being of the residents. While touring the facility LPA noted two bottles of Lysol aerosol spray left out, one in each restroom; an unmarked spray bottle in one bathroom with a liquid in it that staff stated is bleach; in the south side yard a full bottle of tire cleaner; two tubes of hydrocortisone cream 1% and the licensee's personal supplement's in a resident bedroom. All of these items were unattended and accessible to residents in care.

LPA reviewed resident files and medication orders. LPA noted that Resident #1 (R1) has physician order's dated 4/20/2026. The orders include Aspirin 81mg one tablet twice daily, metformin 500mg one tablet by mouth twice daily, and megestrol 800mg/20mL take 20ML by mouth daily; the facility does not have these medications, the licensee states they were discontinued, and they do not have discontinuation orders. The orders also state metformin 5mg take one tablet twice daily and the facility is giving 10mg tablets twice daily. The physician orders for R1 dated 4/20/2026 state insulin at a sliding scale and the licensee stated they are not following these orders, they are following orders provided by R1's responsible party. Licensee states R1's responsible party is not a physician.

Exit interview conducted, deficiencies cited on LIC809-D page, civil penalties in the amount of $250 for a repeat violation are being assessed on the LIC421FCs, report signed, report and appeal rights provided to the Licensee.
NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Garrett Haner-Tomasko
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/13/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 05/13/2026 01:36 PM - It Cannot Be Edited


Created By: Garrett Haner-Tomasko On 05/13/2026 at 12:35 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VALLEY VISTA RESIDENTIAL CARE III
FACILITY NUMBER: 405850047

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/14/2026
Section Cited
CCR
87309(a)

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Storage Space and Access (a) ...the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances,...and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.
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Licensee locked up the items as they were discovered and states they will provide LPA a statement of understanding of how this violation could affect residents and a plan to prevent in the future. They will email this to the LPA on or before 5/20/2026.
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This requirement was not met as evidenced by: Based on observation and record review, the licensee did not ensure poisonous substances and cleaning solutions were inaccessible to residents which poses an immediate health, safety, and personal rights risk to persons in care.
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Type A
05/14/2026
Section Cited
CCR87465(a)(4)

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(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall...provide for assistance in obtaining such care, by compliance with the following:(4)The licensee shall assist residents with self-administered medications as needed.
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Licensee states they will obtain accurate orders for R1 from R1's primary care physican and ensure they have the correct medications by 5/14/2026 and email the orders and photo of medications to LPA on 5/14/2026.
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This requirement was not met as evidenced by: Based on interview and record review, the licensee is not assisting with medication administration per R1's physician orders which poses an immediate health, safety, and personal rights risk to persons in care.
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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.
Kelly Burley
NAME OF LICENSING PROGRAM MANAGER:
Garrett Haner-Tomasko
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2026


LIC809 (FAS) - (06/04)
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