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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603777
Report Date: 09/13/2022
Date Signed: 09/13/2022 03:13:51 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/08/2022 and conducted by Evaluator Tricia Danielson
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220908164041
FACILITY NAME:MARIPOSA MANORFACILITY NUMBER:
374603777
ADMINISTRATOR:WELKER, KELLYFACILITY TYPE:
740
ADDRESS:2525 REED ROADTELEPHONE:
(760) 294-7011
CITY:ESCONDIDOSTATE: CAZIP CODE:
92027
CAPACITY:6CENSUS: 4DATE:
09/13/2022
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Kurt Camalig, CaregiverTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff lock resident in room
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to initiate an investigation into the allegation listed above. LPA met with Caregiver Kurt Camalig and explained the purpose of today's visit. During today's visit, LPA toured room #6, interviewed two (2) staff, two (2) residents and attempted to interview Resident #1 (R1). R1 resides in room #6. Regarding the allegation "staff lock resident in room", it was alleged that staff lock R1 in their room in an effort to control their behaviors. Upon inspection of room #6, LPA observed a white colored, two-pronged latch attached to the outside of the door to room #6. The bottom prong can be engaged in such a way that it prevents the door handle from being manipulated from the inside and thus, preventing anyone from being able to exit the room from the inside. LPA interview with Staff #1(S1) revealed the facility does engage the latch at night to prevent R1 from being able to wonder into other rooms at night. S1 reported the latch is disengaged every morning. LPA observed the latch to be disengaged during today's visit. Based on LPA observations and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC 9099 D. An exit interview was conducted and a copy of this report was provided along with Appeal Rights and LIC811- Confidential Names List.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Tricia Danielson
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 18-AS-20220908164041
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MARIPOSA MANOR
FACILITY NUMBER: 374603777
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/23/2022
Section Cited
CCR
87468.1(a)(6)
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(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(6) To...not be locked into any room, building, or on facility premises by day or night. This requirement was not met as evidenced by: Based on observation and interview conducted, the Licensee did not comply with the section cited above in 1 of 1
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Facility will remove the latch on the door of room #6 and submit a written statement of understanding of the regulation cited. Proof of the latch removal and statement of understanding to be submitted to CCL by POC due date.
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inspections. LPA observed a latch attached to the outside of the door to room #6 which when engaged, is designed to prevent the door from being opened from the inside. S1 reported the latch is engaged at night to prevent R1 from exiting their room. This poses a potential health, safety and personal rights risk to residents 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.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Tricia Danielson
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/08/2022 and conducted by Evaluator Tricia Danielson
COMPLAINT CONTROL NUMBER: 18-AS-20220908164041

FACILITY NAME:MARIPOSA MANORFACILITY NUMBER:
374603777
ADMINISTRATOR:WELKER, KELLYFACILITY TYPE:
740
ADDRESS:2525 REED ROADTELEPHONE:
(760) 294-7011
CITY:ESCONDIDOSTATE: CAZIP CODE:
92027
CAPACITY:6CENSUS: 4DATE:
09/13/2022
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Kurt Camalig, CaregiverTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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9
Staff make resident sleep on the floor
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to initiate an investigation into the allegation listed above. LPA met with Caregiver Kurt Camalig and explained the purpose of today's visit. During today's visit, LPA toured room #6, interviewed two (2) staff, two (2) residents, and attempted to interview Resident #1(R1). Regarding the allegation "staff make resident sleep on the floor", it was alleged that staff make R1 sleep on the floor with the blinds down and light off, even if it is daytime. Upon inspection of room #6, LPA observed the door to be open, the blinds were up allowing daylight in, the light was off, and R1 was asleep in bed the fetal position and was covered with a blanket. LPA observed R1's bed to be in the lowest position, with pads covering the half bed rails, and a foam mattress placed on the floor next to R1's bed. Interview with Staff #1(S1) revealed R1 tends to slide put of bed onto the floor in an effort to get out of bed when they wake up and has had falling incidents as a result. S1 reported that the padding and low bed position has been put in place in an effort to prevent injury. Interviews conducted did not provide any corroborating evidence that staff make any resident sleep on the floor. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted and a copy of this report was provided along with LIC811- Confidential Names List.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Tricia Danielson
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3