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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850047
Report Date: 12/30/2024
Date Signed: 12/30/2024 03:59:58 PM

Document Has Been Signed on 12/30/2024 03:59 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/
DIRECTOR:
CORRALES, NELLIE SFACILITY TYPE:
740
ADDRESS:1557 GALLEON WAYTELEPHONE:
(805) 439-4120
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93405
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 3DATE:
12/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Evelyn Strampe, LicenseeTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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At 10:30am on 12/30/2024, Licensing Program Analyst (LPA) De Leon conducted an unannounced Annual visit to the facility. LPA met with Licensee Evelyn Strampe and explained the purpose of the visit.

This facility is a five bedroom, 2 bathroom, living room, kitchen and dining room with a laundry room behind the kitchen some laundry and cleaning supplies were in the laundry room area not locked due to a resident wandering LPA requested a locking cabinet in the laundry room for these supplies. LPA toured of the facility, This facility has medications in locked drawers in the kitchen area all medication was checked for expiration dates, altered labels and that medication is being stored in original containers, LPA recommended a locked box for medications that needs refrigeration. Staff and Resident files are in a locked cabinet in the dining room area. Resident files were up to date with most forms and missing the updated Appraisal needs and services plans, Administrator will bring them up to date. Administrator files were missing, Administrator will make copies of records at other facility and bring them to this facility. Administrator will send any missing forms to LPA. LPA noted that there are at least two days of perishable foods and at least 7 days of non-perishable foods as well as emergency non-perishable foods. The bathrooms have liquid soap, paper towels,showers have non-slip mats and secured grab bars bare present. Facility has extra resident supplies clean linen and towels for residents use. PPE supplies are available for staffing use and visitors if requested. LPA noted that all resident bedrooms and bathroom have appropriate bedding, linen, and furniture of the resident choice. The facility has a first aid kit. The facility has dual carbon monoxide and smoke detectors. All exits and hallways are free and clear of any obstructions. LPA observed the fire extinguisher to be charged and last inspected on May 21, 2024. The facility was clean, sanitary and in good repair. Kitchen was free of rodents or insects and kept in sanitary condition. LPA reviewed staff and resident files some of the forms where missing and Administrator was completing any necessary forms with family and residents. The outside side gate has normal wear and tear and is no longer self closing or self latching and is in need of repair, Administrator will fix. The annual control tools modules were reviewed with Administrator/Licensee.
Exit interview, deficiencies cited, copy of report and appeal rights printed for Licensee/Administrator.
Kelly BurleyTELEPHONE: (805) 562-0413
Rachael De LeonTELEPHONE: (805) 450-0262
DATE: 12/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/30/2024
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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Document Has Been Signed on 12/30/2024 03:59 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 III

FACILITY NUMBER: 405850047

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 12/30/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2/3 staff did not have health screening with TB results on file at the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/06/2025
Plan of Correction
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Administrator agreed to provide LPA with 2/3 staff's health screeening with TB results.

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 BurleyTELEPHONE: (805) 562-0413
Rachael De LeonTELEPHONE: (805) 450-0262

DATE: 12/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/30/2024

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/30/2024 03:59 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 III

FACILITY NUMBER: 405850047

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 12/30/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in laundry room had cleaning supplies accessible to wandering residents in care which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/06/2025
Plan of Correction
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Administrator agreed to put a lock on the laundry rooms cupboards and store all laundry and cleaning supllies inaccesible to residents in care.
Section Cited
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2/3 staff did not have 1st Aid/CPR certification on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/03/2025
Plan of Correction
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Administrator agreed to provide the Administrator of record and the Licensee current copies of valid first aid and CPR ceritifcations.
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 BurleyTELEPHONE: (805) 562-0413
Rachael De LeonTELEPHONE: (805) 450-0262

DATE: 12/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/30/2024

LIC809 (FAS) - (06/04)
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