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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405802262
Report Date: 12/22/2022
Date Signed: 12/22/2022 11:24:35 AM

Document Has Been Signed on 12/22/2022 11:24 AM - 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:
12/22/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Herbert Hans Salmanca Back up to AdministratorTIME COMPLETED:
11:30 AM
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Licensing Program Analyst's (LPA's) De Leon and Jeffries made an unannounced Plan of Correction visit.. LPA's met with Hans Salamanca back up to Administrator and explained the purpose of the visit.

LPA's cited Licensee on 12/15/2022 for no liability insurance. LPA De Leon requested liability insurance on arrival and Back up to Administrator stated he has not been able to obtain valid liability insurance at this time. Mr. Salamanca stated he is working with a company to get new liability insurance and will need additional time to obtain.

A civil penalty will be issued today for the plan of correction not being submitted.

Exit interview conducted civil penalty assessed on 12/15/2022 809-D with appeal rights. LPA will email copy of report and appeal rights to the Licensee/Administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE: DATE: 12/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/22/2022
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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