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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405801800
Report Date: 07/22/2025
Date Signed: 07/22/2025 05:25:07 PM

Document Has Been Signed on 07/22/2025 05:25 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 CAREFACILITY NUMBER:
405801800
ADMINISTRATOR/
DIRECTOR:		EVELYN S STRAMPEFACILITY TYPE:
740
ADDRESS:1095 SAN ADRIANO STREETTELEPHONE:
(805) 439-0478
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93405
CAPACITY: 6CENSUS: 3DATE:
07/22/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Backup Administrator - Nellie CorralesTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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 At 08:30am, on 07/22/2025, Licensing Program Analyst (LPA) Haner-Tomasko arrived at the facility unannounced to conduct the annual facility inspection. LPA met with Backup Administrator Nellie Corrales and via phone Licensee/Administrator Evelyn Strampe, announced who he was and the reason for the visit.

Prior to today's visit on 7/21/2025 at around 4:44pm LPA researched the standing of the licensee BAYSIDE HOME ENTERPRISES, LLC on California's Secretary of State website and found the status to be "suspended-FTB" as of 6/2/2025. Additionally, LPA noted designated Administrator Evelyn Strampe's administrator certification to not be current on Community Care Licensing Administrator Bureau's website.

During visit, Backup Administrator and LPA conducted a full tour of the facility. This facility has four resident bedrooms (two are dual occupancy), two full bathrooms (one is on-suite to the primary bedroom and one is for public use). LPA interview with backup administrator revealed staff are entering the primary bedroom to access the on-suite bathroom for personal use and the primary bedroom is occupied by a resident. There is a living room, a kitchen and dining area. Access to the laundry room and garage is through a locked door for resident safety.

While touring the kitchen and dining area LPA noted fresh fruit and snacks in the kitchen for residents to enjoy freely. At 9:09am when touring the kitchen LPA noted more than 10 canned and boxed food items to be 5 months to 4 years past the dated shelf life. LPA noted flying insects on apples placed on the table for residents to eat, one of the three apples had a rotting spot.

(Continued on LIC809-C)

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Garrett Haner-Tomasko
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 12
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)
Page: 2 of 12
Document Has Been Signed on 07/22/2025 05:25 PM - It Cannot Be Edited


Created By: Garrett Haner-Tomasko On 07/22/2025 at 03:10 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
FACILITY NUMBER: 405801800

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)(2)
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: (2) Bedridden persons

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above when backup administrator Nellie Corrales stated R1 depends on staff to perform all activities of daily living for them and R1 cannot independently reposition self which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/23/2025
Plan of Correction
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Licensee will communicate with R1's responsible person and physician to see if hospice is an option for R1 and if not Licensee will work with Licesning on next steps of the plan of correction. Licensee will email LPA on or before 7/23/2025 with physician and responsible person decision.
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: 07/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2025


LIC809 (FAS) - (06/04)
Page: 3 of 12
Document Has Been Signed on 07/22/2025 05:25 PM - It Cannot Be Edited


Created By: Garrett Haner-Tomasko On 07/22/2025 at 03:11 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
FACILITY NUMBER: 405801800

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87205(b)
Accountability of Licensee Governing Body
(b) If the licensee is a corporation or an association, the governing body shall be active, and functioning in order to assure accountability.

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 when LPA researched on California Secretary of State and foud the status of the licensee BAYSIDE HOME ENTERPRISES, LLC to be "suspended-FTB" as of 6/2/2025 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/29/2025
Plan of Correction
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Licensee stated they will contact the Secretary of State and Franchise Tax Board to find out how to come into compliance and work to bring the LLC back into good standing by 7/29/2025. Licensee will email LPA on or before 7/29/2025 with status of the LLC.
Type B
Section Cited
CCR
87412(d)
Personnel Records
(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements.

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 when they allowed the administor of the facility Evelyn Strampe to lapse and not be current which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/05/2025
Plan of Correction
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Licensee stated they will schedule the live webinar courses and email LPA the invoice for the courses on or before 8/5/2025.
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: 07/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2025


LIC809 (FAS) - (06/04)
Page: 4 of 12
Document Has Been Signed on 07/22/2025 05:25 PM - It Cannot Be Edited


Created By: Garrett Haner-Tomasko On 07/22/2025 at 03:11 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
FACILITY NUMBER: 405801800

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

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 when LPA observed more than 10 canned and boxed food items 5 months to 4 years past the shelf life date and flying insects on apples placed on the table for residents to eat, one of the three apples had a rotting spot which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/05/2025
Plan of Correction
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Backup Administrator stated they would review and discard all outdated or spoiled food in the facility and email LPA a photo of newly purchased food products and receipt on or before 8/5/2025.
Type B
Section Cited
CCR
87465(h)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored:

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 3 out of 3 resident centrally stored medication records were not completed with all medications currently stored listed which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/19/2025
Plan of Correction
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Backup administrator will ensure all medications currently stored are entered into the centrally stored medication records for all three residents in care. Backup administrator will email LPA the updated records and a statement of understanding of the importance of this regulation and how the facility will comply with it on or before 8/19/2025.
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: 07/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2025


LIC809 (FAS) - (06/04)
Page: 5 of 12
Document Has Been Signed on 07/22/2025 05:25 PM - It Cannot Be Edited


Created By: Garrett Haner-Tomasko On 07/22/2025 at 03:11 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
FACILITY NUMBER: 405801800

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

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 3 out of 3 resident files did not contain a reappraisal conducted in the last 12-months which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/19/2025
Plan of Correction
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Backup administrator will complete a reappraisal for all three residents in care and email them to the LPA on or before 8/19/2025.
Type B
Section Cited
HSC
1569.695(a)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

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 they could not present a completed emergency and disaster plan which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/29/2025
Plan of Correction
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Backup administrator began to complete the facility emergency and disaster plan during LPA visit. Backup administrator will email LPA the completed plan on or before 7/29/2025.
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: 07/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2025


LIC809 (FAS) - (06/04)
Page: 6 of 12
Document Has Been Signed on 07/22/2025 05:25 PM - It Cannot Be Edited


Created By: Garrett Haner-Tomasko On 07/22/2025 at 03:11 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
FACILITY NUMBER: 405801800

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

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 backup administrator could not produce documented drills and stated they think they may have done two which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/05/2025
Plan of Correction
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Backup administrator will conduct an emergency drill with all staff on or before 8/5/2025 and email LPA documentation of the drill and dates of the next three drills for the year on or before 8/5/2025.
Type B
Section Cited
CCR
87608(a)(1)
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (1) Postural supports shall be limited to appliances or devices such as braces, spring release trays, or soft ties, used to achieve proper body position and balance, to improve a resident's mobility and independent functioning, or to position rather than restrict movement including, but not limited to, preventing a resident from falling out of bed, a chair, etc.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above when backup administrator admitted that they get R1 up in a wheelchair, use a seatbelt to keep them from falling out, and R1 cannot unbuckle the restraint themself which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/23/2025
Plan of Correction
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Backup administrator stated they will not use the seatbelt until they start working with responsible person, physician, and Licensing to obtain an exception. Backup administrator will inform LPA of responsible parties decision on R1's status of the facility on or before 7/23/2025 and work with licensing to request an exception.
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: 07/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2025


LIC809 (FAS) - (06/04)
Page: 7 of 12
Document Has Been Signed on 07/22/2025 05:25 PM - It Cannot Be Edited


Created By: Garrett Haner-Tomasko On 07/22/2025 at 03:11 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
FACILITY NUMBER: 405801800

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87615(a)(5)
Prohibited Health Conditions
(a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly:
(5) Residents who depend on others to perform all activities of daily living for them as set forth in Section 87459, Functional Capabilities.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on staff interview, the licensee did not comply with the section cited above when the backup administrator Nellie Corrales stated R1 depends on staff to perform all activities of daily living for them which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/29/2025
Plan of Correction
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2
3
4
Licensee stated they would communicate with R1's responsible person and physician to see if hospice is an option for R1 and if not Licensee will work with Licensing to obtain an exception. Licensee will email LPA on or before 7/29/2025 with physician and responsible person decision.
Type B
Section Cited
CCR
87307(a)(2)(c)
Personal Accommodations and Services
(a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply:
(2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements:
(C) No bedroom of a resident shall be used as a passageway to another room, bath or toilet.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on staff interview, the licensee did not comply with the section cited above when staff stated they use the bathroom with only access through the primary bedroom occupied by a resident for personal use which poses a personal rights risk to persons in care.
POC Due Date: 08/19/2025
Plan of Correction
1
2
3
4
Licensee will ensure staff do not use this bathroom for personal use immediately and provide staff training on this regulation to all staff. Licensee will provide documentation of training and signed staff roster to LPA via email on or before 8/19/2025.
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: 07/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2025


LIC809 (FAS) - (06/04)
Page: 10 of 12
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
FACILITY NUMBER: 405801800
VISIT DATE: 07/22/2025
NARRATIVE
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At 9:15am LPA observed and photographed over twenty bottles and packages of prescription and non-prescription medications belonging to staff in various unlocked cabinets of the dining area and a steak knife in an unlocked kitchen drawer accessible to residents in care.

LPA noted that the backyard and the front yard both have seating and shade for residents and visitors. At 9:23am in the backyard LPA observed and photographed a pocket knife sitting on a dresser, and unlocked in the dresser a bottle of rooting powder, wood stain, a metal dagger, lighter, and two pruning shears. All of these items were accessible to residents in care.

The facility has wired smoke detectors in each room that are all working, the carbon monoxide detector is in the hallway and functioning normally. LPA observed a fire extinguisher near the kitchen that was tagged current and in the green compression range, purchased on 07/22/2025. LPA tested facility hot water at 110.7*(f), within regulation temperatures 105*-120* (f). LPA observed at least 2-days of perishable and at least 7-days of nonperishable foods. LPA noted that the facility has no obstructions in hallways, doorways or exits.

Staff and client files and medications are locked in a cabinet in the kitchen area. LPA conducted a sample medication audit and reviewed the facilities Centrally Stored Medication Records, finding incomplete records for all three residents in care. LPA conducted a staff and resident file review. Resident file review revealed all three residents in care do not have a reappraisal completed in the last 12-months. Facility record review also revealed the facility has an incomplete emergency and disaster plan and quarterly emergency drills have not been completed.

LPA interview with backup administrator revealed Resident #1 (R1) depends on others for all activities of daily living, a prohibited health condition at this type of licensed facility. Backup administrator stated R1 also cannot reposition in bed independently. Interview also revealed staff transfer R1 to a wheelchair and use a seat belt to keep R1 from falling out of the wheelchair. Backup Administrator states R1 is not capable of releasing the seat belt on their own. Record review of R1's file reveals there is no physician order for the seat belt and an exception has not been granted by Licensing for R1's use of a seat belt. Record review also revealed the facility in not cleared for a bedridden room.

(Continued on LIC809-C)

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Garrett Haner-Tomasko
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2025
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
FACILITY NUMBER: 405801800
VISIT DATE: 07/22/2025
NARRATIVE
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 LPA and backup administrator conducted a review of the annual care tool modules.

Exit interview, deficiencies cited on 809-D pages, a civil penalty in the amount of $500 for fire clearance violation is being assessed on the attached LIC 421IM, report, and appeal rights given.

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Garrett Haner-Tomasko
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2025
LIC809 (FAS) - (06/04)
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