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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405802262
Report Date: 05/10/2021
Date Signed: 05/10/2021 06:04:04 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/09/2021 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20210409162916
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: DATE:
05/10/2021
UNANNOUNCEDTIME BEGAN:
04:16 PM
MET WITH:Herbert "Hans" SalamancaTIME COMPLETED:
06:01 PM
ALLEGATION(S):
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Resident was restrained in a wheelchair.
Medications were improperly stored.
Dangerous items were not secured.
Facility is not kept clean and sanitary
Facility staff lack training to safely transfer residents in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to deliver final findings in the investigation. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted virtually with Licensee/Administrator Herbert Salamanca. LPA explained the purpose of today’s visit was to deliver the findings in the complaint investigation.

On the allegation: Resident was restrained in a wheelchair. LPA conducted interview with Credible Witness 1 (W1) revealing W1 observed on 04/06/2021 Resident 1 (R1) was unable to stand up due to being in a wheelchair (W/C) with a lap belt that the resident was not able to release on own. Documentation revealed R1 is non-ambulatory. Interview with Staff 1 (S1) revealed R1 came to the facility with the wheelchair and belt
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2021
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 6
Control Number 29-AS-20210409162916
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 CARE
FACILITY NUMBER: 405802262
VISIT DATE: 05/10/2021
NARRATIVE
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On the allegation: Facility is not kept clean and sanitary. LPA interviewed W1 regarding observations made at the facility. W1 reported that the kitchen floor was sticky on 04/06/2021 and the bathroom floor had dirt and debris at the bottom of the walls and corners on 04/08/2021. On 04/16/2021 at approximately 12:000 pm LPA observed some debris in the corners of the bathroom floor. Based on observations made this allegation is deemed Substantiated at this time.

On the allegation: Facility staff lack training to safely transfer residents in care. LPA interviewed W1 regarding the observations made at the facility. W1 reported S2 was assisting R2 with a transfer to the wheelchair and S2 did not set the breaks on the wheelchair before assisting R2 with the transfer. LPA reviewed the training documentation on 04/19/2021 at 8:30 am and the training documentation does not meet the requirements set in regulation for proper training of staff. Therefore, the allegation is deemed Substantiated at this time.

Exit interview conducted, deficiencies cited, copy of report and appeal rights emailed to Licensee to sign and return to the Goleta office.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 29-AS-20210409162916
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 CARE
FACILITY NUMBER: 405802262
VISIT DATE: 05/10/2021
NARRATIVE
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from previous facility on hospice services. S1 was able to provide a written physicians order for the W/C lap belt, but the order was written after LPA requested the documentation on 04/16/2021. Regulation requires that postural supports shall be fastened or tied in a manner that permits quick release by the resident and R1 is unable to release belt on own, therefore the allegation is deemed Substantiated at this time.

On the allegation: Medications were improperly stored. LPA conducted a physical plant tour of the facility on 04/16/2021 at 11:42 AM. During the tour LPA observed the laundry room door does have a locking latch that slides to lock at the top of the door to enter but does not have a locking door knob/handle, in the laundry room area was a shelving unit containing distilled water, syrup, cleaning products, personal grooming and hygiene items that were all mixed together on the shelving unit, the medication was stored in the laundry room lower cabinets with other items, cleaning products and a plastic box with lid containing kitchen knives/sharps. LPA observed a locked office door, in the office was magnetic locked cabinets containing paperwork, medications and the magnetic key was hanging beside the cabinets. On 04/06/2021 W1 observed medication in the dishwasher and in an unlocked lower cabinet in the laundry room. On a follow up visit on 04/08/2021 W1 observed that some medication remained in the refrigerator, not in the locked box. Other medication was left in an unlocked bottom cabinet in the laundry room and other medication was in the office cupboard locked with a magnetic locking system with the magnetic key hanging right next to the cabinet. LPA explained to the Licensee that medication, records, kitchen utensils/knives/sharps, and cleaning products needed to be locked, stored separately and the magnetic key needed to be secured. Based on the observations made this allegation is deemed Substantiated at this time.

On the allegation: Dangerous items were not secured. LPA interviewed W1 regarding the observations made at the facility. W1 observed kitchen knives in an unlocked drawer in the kitchen on 04/06/2021 and 04/08/2021. LPA observed on 04/16/2021 the kitchen knives in a plastic box with lid in lower cabinet in the laundry room mixed with cleaning products and medications. LPA explained to the Licensee that each item needed to be stored locked. Based on the observations made this allegation is deemed Substantiated at this time.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20210409162916
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 CARE
FACILITY NUMBER: 405802262
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
05/14/2021
Section Cited
CCR
87608(a)(2)
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87608 Postural Supports ... (2)Postural supports shall be fastened or tied in a manner that permits quick release by the resident. This requirement was not met as evidenced by:
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Licensee agreed to read, review regulation 87608 for compliance, maintain a physicians order for W/C lap belt in the residents file and request an exception for R1’s use of the w/c lap belt.
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Based on W1 interview Licensee did not comply, R1 was not able to release lap belt on wheelchair which poses an immediate health, safety, personal rights risk to residents in care.
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Request Denied
Type A
05/11/2021
Section Cited
CCR
87465(h)(2)
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87465 Incidential Medical and Dental Care (2)Centrally stored medicines shall be kept in a safe and locked place ... This requirement was not met as evidenced by:
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Licensee agreed to read, review regulations 87465, provide a locked location for medications, and the pictures of cabinet and locks, take a picture of the refrigerator medication locked.
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Based on LPA and W1 observation Licensee did not comply, medications were being stored in several unlocked locations which poses an immediate health and safety 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: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 29-AS-20210409162916
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 CARE
FACILITY NUMBER: 405802262
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
05/11/2021
Section Cited
CCR
87705(f)(1)
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87705 Care of Persons with Dementia ...(1)Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement was not met as evidenced by:
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Licensee agreed to read, review regulation 87705, provide a locked drawer for knives and other sharp objects, take a picture of the drawer and lock. Send proof to CCL.
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Based on W1 observation Licensee did not comply, knives were left in an unlocked drawer in the kitchen which poses a potential health and safety risk to residents in care.
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Request Denied
Type B
05/14/2021
Section Cited
CCR
87303(a)(1)
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87303 Maintenance and Operation ...(1)Floor surfaces in bath, laundry,kitchen areas shall be maintained in a clean, sanitary, ... This requirement was not met as evidenced by:
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Licensee agreed to read, review regulation 87303, floors and walls in the kitchen and bathroom cleaned and disinfected and send photographic proof to CCL.
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Based on LPA and W1 observation the Licnesee did not comply, the bathroom and kitchen floors were not clean and sanitary which poses a potential health and safety 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: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 29-AS-20210409162916
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 CARE
FACILITY NUMBER: 405802262
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
05/14/2021
Section Cited
CCR
87411(c)(4)(C)
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87411 Personnel Requirements ... (C) ... and with a record of administering facilities in substantial compliance ... This requirement was not met as evidenced by:
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Licensee agreed to read, review regulation 87411, to have staff trained by a qualified representative that meets regulation requirements, send proof of staff training to CCL.
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Based on documentation Licensee did not comply, Training done by Administrator not in substantial compliance which poses a potential 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: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 6