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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405802262
Report Date: 09/16/2021
Date Signed: 09/16/2021 04:40:57 PM

Document Has Been Signed on 09/16/2021 04:40 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:CHERYLL Y ESTACIOFACILITY TYPE:
740
ADDRESS:130 E BRANCH STREETTELEPHONE:
(805) 636-8489
CITY:NIPOMOSTATE: CAZIP CODE:
93444
CAPACITY: 6CENSUS: 2DATE:
09/16/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:38 PM
MET WITH:Staff Virigina AmbosTIME COMPLETED:
02:55 PM
NARRATIVE
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Licensing Program Analyst (LPA) De Leon conducted a Case Management Health and Safety check on residents in care. LPA met with staff caregiver Virigina Ambos and explained the purpose of the visit.

LPA took a tour of the inside of the facility. LPA observed 2 residents in care, neither resident had any concerns at the time.

LPA's De Leon and Jeffries contacted the Licensee's facilities. The above facility did not answer and a voice mail was left with no one reply. LPA De Leon and Jeffries left voice mails on the facility cell phones on record with no response.

LPA De Leon visited the facility to check on the resident's in care and to make sure the facility has a working telephone
.
The telephone on record was called by LPA De Leon and it did not ring in the facility. LPA De Leon used the facility phone to call LPA's cell number and it did place the cal but when calling the facility number came up differently and did not match the facility telephone on file.

LPA De Leon will update the facility phone number on file.

Exit interview conducted, no deficiency cited at this time, copy of report emailed to the Licensee/Administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE: DATE: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2021
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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