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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405802262
Report Date: 12/15/2022
Date Signed: 12/15/2022 04:28:31 PM

Document Has Been Signed on 12/15/2022 04:28 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:MIRIAM SALAMANCAFACILITY TYPE:
740
ADDRESS:130 E BRANCH STREETTELEPHONE:
(805) 619-7642
CITY:NIPOMOSTATE: CAZIP CODE:
93444
CAPACITY: 6CENSUS: 2DATE:
12/15/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:StaffTIME COMPLETED:
04:35 PM
NARRATIVE
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Licensing Program Analysts (LPA's) De Leon and Jeffries conducted a case management (CM) visit to the facility above. LPA's met with Staff, Licensee Herbert "Hans" Salamanca was unable to make the visit. LPA explained to staff the purpose of the visit.

Community Care Licensing received United States Postal Service (USPS) mail from the facility insurance company that the Liability insurance was being cancelled for non-payment. LPA De Leon called Licensee on 11/21/2022 requested a new copy of liability insurance and Licensee explained at the time they were in the process of obtaining new insurance and it would be about 3 weeks before they could provide evidence of new insurance records.

LPA De Leon requested a new copy of the facility liability insurance today and Licensee said they were in the process of obtaining but did not have any current records of proof of insurance. Licensee stated he could provide the paperwork of it being in process if needed.

As of today 12/15/2022 the facility does not have current liability insurance.

Exit interview conducted, deficiency cited, copy of report and appeal rights emailed to Licensee.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE: DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/15/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 12/15/2022 04:28 PM - It Cannot Be Edited


Created By: Rachael De Leon On 12/15/2022 at 04:21 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: 12/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/16/2022
Section Cited
HSC
1569.605

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Liability insurance;...requirements....
all residential care facilities for the elderly..., shall maintain liability insurance covering injury to residents....This requirement was not met as evidence by:
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Licensee agreed to provide a current record of liability insurance meeting HSC requirements and provide a copy to the department.
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Based on interview the Licensee did not comply with the regulation above the facility does not have record of current liability insurance which posses 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.
SUPERVISOR'S NAME:Kelly Burley
LICENSING EVALUATOR NAME:Rachael De Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2022


LIC809 (FAS) - (06/04)
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