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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405802262
Report Date: 04/12/2021
Date Signed: 04/12/2021 06:08:19 PM

Document Has Been Signed on 04/12/2021 06:08 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:VILLA MARIPOSA SENIOR CAREFACILITY NUMBER:
405802262
ADMINISTRATOR:SALAMANCA, MIRIAMFACILITY TYPE:
740
ADDRESS:130 E BRANCH STREETTELEPHONE:
(805) 636-8489
CITY:NIPOMOSTATE: CAZIP CODE:
93444
CAPACITY: 6CENSUS: 3DATE:
04/12/2021
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
05:26 PM
MET WITH:Hans SalamancaTIME COMPLETED:
06:08 PM
NARRATIVE
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Licensing Program Analyst (LPA) De Leon conducted a Case Management visit to the facility above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s visit was conducted by Telephonic video with the Licensee Hans Salmanca at 5:26 PM, LPA explained the purpose of the visit.

On 04/06/2021, a credible witness 1 (CW1) visited the facility and observed Staff 1 (S1) not wearing a mask. According to CW1, the staff answered the door without a mask on, once in the facility CW1 requested S1 put on mask for the safety of residents in care, then S1 proceeded to put on the mask upside down. The licensee failed to protect the personal rights of residents in care to be able to receive safe and healthful accommodations, in that the facility staff (S1) failed to wear face coverings while providing care and supervision to residents in care. This is a violation of official government orders requiring the wearing of face coverings while working under specified conditions.

Pursuant to Title 22, California Code of Regulations, the deficiency will be cited on 809-D.

Exit interview conducted, deficiency cited, copy of report and appeal rights provided through email to Licensee. Licensee will print, sign and return a copy to the Goleta office by mail.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE: DATE: 04/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/12/2021
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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Document Has Been Signed on 04/12/2021 06:08 PM - It Cannot Be Edited


Created By: Rachael De Leon On 04/12/2021 at 05:44 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: VILLA MARIPOSA SENIOR CARE
FACILITY NUMBER: 405802262

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/19/2021
Section Cited
CCR
87468.1(a)(2)

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87468.1 Personal Rights of Residents in All Facilities(a)...(2) To be accorded safe, healthful... accommodations, furnishings and equipment. This requirement was not met as evidenced by:
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Licensee agreed to mandate mask wearing by all staff in the facility, will provide infection control training to staff and provide proof of training to CCL.
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Based on CW1's statement the Licensee did not comply, S1 was not wearing a face covering while in the facility which poses an immediate 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.
SUPERVISOR'S NAME:Kelly Burley
LICENSING EVALUATOR NAME:Rachael De Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2021


LIC809 (FAS) - (06/04)
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