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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850047
Report Date: 11/05/2022
Date Signed: 11/05/2022 04:36:26 PM

Document Has Been Signed on 11/05/2022 04:36 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:CORRALES, NELLIE SFACILITY TYPE:
740
ADDRESS:1557 GALLEON WAYTELEPHONE:
(805) 439-4120
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93405
CAPACITY: 6CENSUS: 5DATE:
11/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:49 AM
MET WITH:Evelyn Strampe/LicenseeTIME COMPLETED:
02:00 PM
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At 11:00am on 11/05/2022, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to conduct the annual infection control inspection. LPA met with Licensee Evelyn Strampe and announced the reason for the visit.
This facility is a five bedroom, 2 bathroom, living room, kitchen and dining room with a laundry room behind the kitchen. LPA conducted a cursory tour of the facility, This facility has medications in the locked drawer in the kitchen area, Staff and Resident files are in a locked cabinet in the dining room area. LPA noted that there are at least two days of perishable foods and at least 7 days of non-perishable foods. LPA noted that Licensee was in the middle of accepting a resident back from the hospital at their other facility. LPA noted that the facility has at least 30 days of PPE on hand and all bathrooms have liquid soap and paper towels. LPA noted that the facility has 30 days of incontinent supplies. Licensee also has another facility and family has additional facility in the immediate area to mitigate any PPE or other supply issues that may occur.

LPA and Licensee conducted the infection control portion of the annual infection control inspection. LPA noted that upon entrance staff was not wearing mask and had no exemption and was not in the course of eating and therefore section 109 of the infection control module for face coverings was issued as a technical assistance violation. LPA noted that there were no other violations of the infection control module portion of the annual inspection. LPA noted that one Technical Assistance violation was cited on this annual inspection.

Exit interview, technical assistance cited, report signed, and report emailed.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE: DATE: 11/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2022
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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