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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405850047
Report Date: 05/06/2025
Date Signed: 05/06/2025 10:33:20 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/27/2025 and conducted by Evaluator Garrett Haner-Tomasko
COMPLAINT CONTROL NUMBER: 29-AS-20250427204627
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: 3DATE:
05/06/2025
UNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Licensee - Evelyn StrampeTIME COMPLETED:
10:50 PM
ALLEGATION(S):
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Staff left residents unattended
INVESTIGATION FINDINGS:
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On 05/06/2025 at 08:40am Licensing Program Analyst (LPA) Haner-Tomasko arrived unannounced at the facility to investigate the allegation to this complaint. LPA met with Licensee - Evelyn Strampe and explained the purpose of the visit. During the visit, LPA toured the facility, checked the well-being of the residents, interviewed the Licensee, a resident, and obtained relevant documents.

On the allegation: Staff left residents unattended. It was alleged, on 4/23/2025 there were no staff on the facility premises for a period of time between 1:00 pm and 2:00 pm. During LPA interview with the Licensee, the Licensee stated they left the facility unattended for 15-20 minutes to get fresh produce at the store close by. The Licensee stated no other staff were on the premisis and they left two residents unattended for that time period. Based on the information obtained, the allegation is deemed Substantiated at this time.

Exit interview, deficiencies cited on 9099-D, civil penalty assessed, copy of report given, appeal rights given.
Substantiated
Estimated Days of Completion: 90
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Garrett Haner-TomaskoTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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Control Number 29-AS-20250427204627
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 III
FACILITY NUMBER: 405850047
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/07/2025
Section Cited
CCR
87411(a)
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Personnel Requirements. (a)Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by:
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Licensee agrees to provide LPA with a signed letter of understanding of Title 22, Division 6, Chapter 8, Article 7, Regulation 87411(a) and a written plan with measures to ensure staff are on the premises at all times by 05/07/2025.
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Based on interview, the Licensee did not comply with the section cited above when they left the facility to go shopping leaving residents unattended, which posed an immediate health and safety risk to residents 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.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Garrett Haner-TomaskoTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2025
LIC9099 (FAS) - (06/04)
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