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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405802262
Report Date: 08/10/2021
Date Signed: 08/10/2021 02:32:26 PM

Document Has Been Signed on 08/10/2021 02:32 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: DATE:
08/10/2021
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Herber and Miriam SalamancaTIME COMPLETED:
02:30 PM
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An Informal Conference was conducted today in the Goleta Office. The purpose of the Informal Conference was to discuss deficiencies cited for the licensee’s three facilities (Miriam’s Place, Villa Mariposa Senior Care, and SingleTree Caring Hands).

Present at today’s meeting were: Kelly Burley, Licensing Program Manager; Rachael De Leon, Licensing Program Analyst; Mark Jeffries, Licensing Program Analyst; Miriam Salamanca, Licensee/Administrator; Herbert Salamanca, Licensee/Administrator.

The Informal Conference process was explained to the Licensee. The Licensee was notified that this Informal Conference is a part of the Administrative Action process and that further citations may result in Probation or a formal Non-Compliance Plan, which could then lead to a referral to the Department's Legal Division for possible Administrative Action.



Today's conference addressed the following issues:
- Repeat violations of the same regulation
- Promptly submitting Plans of Correction (POCs) and other requested documentation
- Medications must be locked, given as prescribed, the labels cannot be altered, medications must be logged properly on the Centrally Stored Medication Record.
- Ensuring staff have fingerprint clearance before working
- Staff must be trained adequately and it must be documented
- Facilities must ensure sufficient staffing
- Training of staff must be done and records must be kept current for all training of staff
- Safety of residents with dementia; physical plant.
- Proper supervision of residents so they do not elope
Continued 809-C
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE: DATE: 08/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/10/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 08/10/2021
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- Ensure staff wear proper PPE in the facility, including masks at all times.
- Submit incident reports
- Ensuring Licensees understands the importance of correcting previously cited violations.
- Ensure annual fees are paid, as one facilities’ annual fees are not current.

LPM will give until 8/17/2021 to have the following deficiencies corrected and provide proof to CCL:


POC for postural supports/exception needed, and POC for training. Failure to fulfill the POC by this date will result in civil penalties for failure to correct.

LPM Burley encouraged the Licensees to check the Provider Information Notices (PINs) on CCLD's website (www.ccld.ca.gov).

LPM Burley also discussed the Licensees have been referred to the Technical Support Program, but later changed their mind and did not want to participate. LPM Burley encouraged Licensees to participate, as the Program is designed to help bring facilities into compliance. Licensee agreed to accept TSP services.

Exit interview. Report given

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2021
LIC809 (FAS) - (06/04)
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