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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850047
Report Date: 01/05/2024
Date Signed: 01/05/2024 01:29:51 PM


Document Has Been Signed on 01/05/2024 01:29 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 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: 4DATE:
01/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Licensee - Evelyn StrampeTIME COMPLETED:
01:35 PM
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 At 8:20am on 01/05/2024, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to conduct the annual. LPA was met at the facility entrance by unknown person, not on the facility Guardian or LIS rosters, and conducted a case management visit in addition to this annual report. LPA met with Licensee Evelyn Strampe and announced the reason for the visit.

This facility is a five bedroom, 2 bathroom, living room, kitchen and dining room with a laundry room behind the kitchen. LPA conducted a cursory tour of the facility, This facility has medications in the locked drawer in the kitchen area, Staff and Resident files are in a locked cabinet in the dining room area. LPA noted that there are at least two days of perishable foods and at least 7 days of non-perishable foods. LPA noted that the facility has at least 30 days of PPE on hand and all bathrooms have liquid soap and paper towels. LPA noted that the facility has 30 days of incontinent supplies. LPA noted that all resident bedrooms and bathroom have appropriate bedding, linin, and furniture. LPA noted that there is a first aide kit with all necessary kit tools. LPA noted that there is a working carbon monoxide detector and smoke detectors that are functioning throughout the facility. All exits and hallways are free and clear of debris. LPA observed the fire extinguisher to be in the green reading. LPA noted that the facility was clean and in good repair. LPA reviewed staff and resident files and found no apparent issues with facility files.

The Licensee and LPA conducted a full review of the annual control tools modules. LPA noted that there were no technical, violations, or citations noted during the full review of the annual control tools modules. LPA noted that there was a case management report during the time of this visit on a separate report pertaining to Personnel Requirements, General. LPA noted that no other violations, or citations were issued on this report.

Exit interview, report read, and report provided.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:
DATE: 01/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/05/2024
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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