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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850047
Report Date: 09/30/2026
Date Signed: 09/30/2026 05:35:38 PM

Document Has Been Signed on 09/30/2026 05:35 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:		EVELYN STRAMPEFACILITY TYPE:
740
ADDRESS:1557 Galleon WAYTELEPHONE:
(805) 439-4120
CITY:San Luis ObispoSTATE: CAZIP CODE:
93405
CAPACITY: 6CENSUS: 4DATE:
09/30/2026
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Licensee/Administrator - Evelyn StrampeTIME VISIT/
INSPECTION COMPLETED:
05:45 PM
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On 9/30/2026 at 1:15pm, Licensing Program Analyst (LPA) Haner-Tomasko conducted an unannounced Case Management - Legal/Non-Compliance visit. The purpose of today’s visit was to ensure the facility is maintaining substantial compliance as discussed in the Non-Compliance Conference (NCC) that took place on 8/18/2026. As a result of the NCC, the licensee is placed on frequent monitoring for a period of two years. LPA met with Licensee/Administrator Evelyn Strampe and explained the reason for the visit.

During today's visit LPA and Licensee conducted a tour of the facility. Upon arriving to the facility at 1:15pm LPA noted the garage door was open and no staff or residents were in the area. LPA noted a serrated bread knife with a black handle and approximate nine (9) inch blade placed on top of boxes, five bottles of Lysol toilet cleaner, three aerosol cans of Lysol disinfectant, and a spray bottle of all purpose car cleaner. At 1:44pm LPA noted in the shed in the backyard that was unlocked two additional bottles of aerosol Lysol disinfectant. LPA noted the back of the shed was also missing metal panels creating a large hole and the floor of the shed contained rodent feces. During the tour LPA also noted that Resident #1 (R1) had full length bed rails attached to their bed, interviews revealed R1 was previously on service with hospice but graduated off approximately the first week of August 2026. LPA also noted an audio/video monitoring device on the kitchen counter. When asked about the device the Licensee stated they placed a camera in R1 and Resident #2's (R2's) bedroom to monitor them and neither resident provided consent for the cameras.

LPA and Licensee reviewed the centrally stored medication and destruction records (CSMDRs). Licensee stated they have not conducted a medication audit as discussed during the NCC due to scheduling issues with the nurse they are making arrangements with.

(Continued on LIC809-C)
Kelly Burley
Garrett Haner-Tomasko
DATE: 09/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2026
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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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: 09/30/2026
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While reviewing the CSMDRs LPA noted Resident #3 (R3) has a physician order for Tylenol PRN and a note from the physician stating they cannot determine their need for the PRN medication and cannot communicate their symptoms indicating the need for the medication. Licensee states that R3 does occasional take the PRN Tylenol but there is no documentation of R3's physician being contacted or the date/time, dosage taken, or R3's response tot he medication.

Additionally during review of the centrally stored medications the LPA noted two (2) of four (4) residents pills had been transferred into weekly pill dispensers despite a citation previously being issued for this violation.

Exit interview conducted, deficiencies cited on LIC9099-D pages, two civil penalties in the amount of $250 for a repeat of the same violation within 12-months are being assessed on the attached LIC 421FCs, 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: 09/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/30/2026 05:35 PM - It Cannot Be Edited


Created By: Garrett Haner-Tomasko On 09/30/2026 at 03:34 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: 09/30/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/14/2026
Section Cited
CCR
87468.2(a)(1)

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Personal Rights. (a)(1) To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the internet, and meetings of resident and family groups.
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Licensee removed the camera's from R1 and R2's room during LPA visit. They state they will also create a statement of understanding explaining how this regulation relates to placing audio/video devices in a residents room and email to the LPA by 10/14/2026.
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This requirement was not met as evidenced by: Based on interview and observation, the licensee placed video cameras in two (2) of four (4) residents rooms without resident consent which poses a potential Personal Rights risk to persons in care.
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Type B
10/14/2026
Section Cited
CCR87608(a)(5)(B)

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(a)...Postural supports may be used under the following conditions. (5) ... (B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.
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Licensee removed the rails during LPAs visit. They state they will also create a statement of understanding as tot he hazards full rails present to R1 and email to the LPA by 10/14/2026.
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This requirement was not met as evidenced by: Based on interview and observation, the licensee allowed R1 to have ful bed rails when R1 was not on hospice care which poses a potential Health and safety risk to persons 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.
Kelly Burley
NAME OF LICENSING PROGRAM MANAGER:
Garrett Haner-Tomasko
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/30/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/30/2026 05:35 PM - It Cannot Be Edited


Created By: Garrett Haner-Tomasko On 09/30/2026 at 04:01 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: 09/30/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/01/2026
Section Cited
CCR
87309(a)

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(a)... the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives... 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:
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Licensee enssured the items were locked up during LPA visit. Licensee states they will create a log to record daily checks of the facility to ensure hazardous items are locked and will email the completed log showing they are conducting daily checks to the LPA on 10/14/2026.
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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 and personal rights risk to persons in care.
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Type A
10/01/2026
Section Cited
CCR87465(h)(5)

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(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.
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Licensee states they will provide another statement of understanding as to why this regulation exists and the hazards it poses to residents and email this to the LPA by 10/1/2026
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Based on observation and interview, the licensee did not comply with the section cited above when they transfered medciations into weekly pill containers for resident medications which poses an immediate health and safety risk to persons 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.
Kelly Burley
NAME OF LICENSING PROGRAM MANAGER:
Garrett Haner-Tomasko
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/30/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2026


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 09/30/2026 05:35 PM - It Cannot Be Edited


Created By: Garrett Haner-Tomasko On 09/30/2026 at 04:31 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: 09/30/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/14/2026
Section Cited
CCR
87465(d)

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(d) ...facility staff designated by the licensee, shall be permitted to assist the resident with self-administration provided all of the following requirements are met:
(3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record.
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Licensee will create a written protocol on how they follow Title 22 regulations 87465(b) - (e) and email the protocol to the LPA by 10/14/2026.
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This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above when they did not keep records when providing R3 PRNs which poses an immediate health and safety risk to persons in care.
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Type B
10/14/2026
Section Cited
CCR87303(a)

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(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidenced by:
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 Licensee states they will fix the hole in the shed and contact a pest control agency to see what options they have to safely mitigate pests on the facility property. Licensee will email photos of repaired shed and results of pest control inquiry to LPA by 10/14/2026.
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Based on observation and interview, the licensee did not comply with the section cited above when they did not keep the facility clean of rodent feces which poses an potential health and safety risk to persons 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.
Kelly Burley
NAME OF LICENSING PROGRAM MANAGER:
Garrett Haner-Tomasko
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/30/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2026


LIC809 (FAS) - (06/04)
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