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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 10:58:03 AM

Document Has Been Signed on 01/05/2024 10:58 AM - 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:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:25 AM
MET WITH:Licensee - Evelyn StrampeTIME COMPLETED:
11:26 AM
NARRATIVE
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 At 8:20am on 01/05/2024, Licensing Program Analyst (LPA) Jeffries arrived at the facility to conduct an unannounced annual inspection. Upon arrival LPA was greeted at the door by Henie Cabrilla. LPA announced who he is and the reason for the visit. LPA asked for the Administrator and the Administrator was not present. LPA observed Henie Cabrilla adjust resident in chair then working the the facility kitchen, and additionally stated "I just fed the residents", when asked by LPA if he could sit at the table. LPA interviewed Henie Cabrilla while waiting for the Administrator/Licensee to arrive and discovered that Henie Cabrilla was a sibling of the Administrator and had been visiting for "about a month". Additionally, Henie Cabrilla was leaving the facility on Sunday 01/07/2024, then returning to the Philippines on 01/26/2024. LPA pulled LIS facility roster and pulled Guardian roster for this facility and Henie Cabrilla was not cleared on either roster and denied having been fingerprinted. Administrator Evelyn Strempe arrived approximately 15 minutes after LPA initially arrived at the facility. LPA notified Administrator and Henie Cabrilla that they were not cleared on the facility roster, not fingerprinted and therefore could not provide care for Residents and at all times when it the facility had to have a cleared staff present if they were visiting. Administrator and Henie Cabrilla stated that they both understood and subsequently a citation is issued. LPA continued annual facility inspection on a separate report on this same visit.

Exit interview, report read, citation issued, appeal rights and report provided.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
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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Document Has Been Signed on 01/05/2024 10:58 AM - It Cannot Be Edited


Created By: Mark Jeffries On 01/05/2024 at 10:38 AM
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: 01/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/05/2024
Section Cited

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87411 Personnel Requirements - General (g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: (1)Obtain a California clearance or a criminal record exemption as required by law or Department regulations. This requirement
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was not met by evidence of LPA observing Henie Cabrilla providing direct care to resident. Which poses a potential risk to resident 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 Burley
LICENSING EVALUATOR NAME:Mark Jeffries
LICENSING EVALUATOR SIGNATURE:
DATE: 01/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/05/2024


LIC809 (FAS) - (06/04)
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