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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850047
Report Date: 12/31/2025
Date Signed: 12/31/2025 03:34:13 PM

Document Has Been Signed on 12/31/2025 03:34 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:		CORRALES, NELLIE SFACILITY TYPE:
740
ADDRESS:1557 GALLEON WAYTELEPHONE:
(805) 439-4120
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93405
CAPACITY: 6CENSUS: 6DATE:
12/31/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Licensee - Evelyn StrampeTIME VISIT/
INSPECTION COMPLETED:
03:20 PM
NARRATIVE
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At 9:45am, on 12/31/2025, Licensing Program Analyst (LPA) Haner-Tomasko arrived at the facility unannounced to conduct the annual facility inspection. LPA met with Licensee Evelyn Strampe, announced who he was and the reason for the visit.
Licensee and LPA conducted a full tour of the facility. This facility is a single story residential home with five resident bedrooms (one is dual occupancy), two full bathrooms. There is a living room with dining space and a kitchen. There is access to the laundry area off the kitchen as it also gives access to an emergency exit and one of the full bathrooms. At 9:57am in the laundry area LPA observed an open package of laundry detergent pods, two aerosol cans of Lysol disinfectant and bottles of rubbing alcohol not locked up accessible to residents; at 10:05am in the kitchen LPA observed medications not secure in the refrigerator and a sharps container with used syringes with needles not secure sticking plunger side up out the top of the sharps container accessible to residents in care; at 10:11am in a dresser behind the living room couch LPA observed approximately 9 bottles of the Licensees personal medications not locked up accessible to residents in care; and at 10:26am in the backyard on the south side of the facility a half bottle of Clorox stain remover and half bottle of hair & grease drain opener also accessible to residents in care. LPA observed boxes and clothing blocking the emergency exit off the laundry area and a night stand blocking the emergency exit off the bedroom to the left of the front door of the facility.
LPA noted that the backyard and the front yard both have seating and shade for residents and visitors. LPA noted fresh fruit in the kitchen for residents to enjoy. LPA tested facility hot water at 109*(f), within regulation temperatures 105*-120* (f). LPA observed at least 2-days of perishable and at least 7-days of nonperishable foods.
(Continued on LIC809-C)
NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Garrett Haner-Tomasko
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/31/2025
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 12/31/2025 03:34 PM - It Cannot Be Edited


Created By: Garrett Haner-Tomasko On 12/31/2025 at 01:18 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: 12/31/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.269(a)(10)
Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights: (10) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based admission the licensee did not comply with the section cited above by using a gait belt to restrain R1 to a chair in the living room on multiple occasions which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/01/2026
Plan of Correction
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Licensee states they will no longer use a restraint and email the LPA a statement of understanding of this regulation, the use of restraints, and no longer using them on this resident. Licensee will also conduct with all staff training given by a licensed vendor on postural supports and restrictions of using restraints in the facility and email training and signed staff roster to LPA on or before 1/28/2026.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 12/31/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/31/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/31/2025 03:34 PM - It Cannot Be Edited


Created By: Garrett Haner-Tomasko On 12/31/2025 at 01:40 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: 12/31/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, 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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above when they left hazardous items accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/01/2026
Plan of Correction
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Licensee locked items up at the time of LPA visit and will conduct training with all staff on this regulation and the hazards posed to residents in care. Licensee will email LPA training documentation and signed staff roster on of before 1/28/2026.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 12/31/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/31/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/31/2025 03:34 PM - It Cannot Be Edited


Created By: Garrett Haner-Tomasko On 12/31/2025 at 01:40 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: 12/31/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

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 by allowing two emergecny exits to be blocked which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/14/2026
Plan of Correction
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Licensee removed items blocking the exits during LPA visit. Licensee will conduct training with all staff on ensuring emergency exits and passageways are clear and email LPA training documentation and signed staff roster on or before 1/14/2026
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 12/31/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/31/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/31/2025 03:34 PM - It Cannot Be Edited


Created By: Garrett Haner-Tomasko On 12/31/2025 at 01:44 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: 12/31/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by retaining a R2 who is bedridden without a bedridden fire clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/01/2026
Plan of Correction
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Licensee will work with LPA of come into compliance with the regulation. Licensee will write a statement of understanding and email LPA by 1/1/2026.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 12/31/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/31/2025


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
VISIT DATE: 12/31/2025
NARRATIVE
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 LPA conducted a resident record review finding four of the six residents are at risk if given direct access to hazardous items (disinfectants, poisons, etc.) and LPA observed three of those four residents walk independently in the facility during the visit. During resident record review Licensee admitted they use a gait belt to keep Resident #1 (R1) in a recliner in the living room to prevent the resident from wandering or getting up to go out a door. LPA reviewed with the Licensee that this is a restraint and cannot be used for this purpose. LPA cited a deficiency and the Licensee stated they will not restrain the resident further. Resident record review also revealed Resident #2 (R2) is considered bedridden and this facility does not have a fire clearance for a bedridden room. Licensee stated to LPA they have not seen R2 turn or reposition in bed independently recently as they provide R2 all mobility assistance and R2 likely cannot follow instruction to do so independently.

LPA and Licensee conducted a partial review of the annual care tool modules. LPA will have to return to finish the annual visit at a later date.

Exit interview conducted, deficiencies cited on LIC809-D pages, 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: 12/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2025
LIC809 (FAS) - (06/04)
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