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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405802262
Report Date: 02/16/2023
Date Signed: 02/16/2023 10:25:03 AM

Document Has Been Signed on 02/16/2023 10:25 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: 4DATE:
02/16/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Hans Salamanca, AdministratorTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) De Leon conducted a case management visit to the facility above to check on residents that relocated from Licensee prior facility and the current financial records for the facility. LPA met with Hans and Miriam Salamanca Licensee/Administrators and explained the purpose of the visit.

LPA toured facility with Administrator. The residents were finishing breakfast upon LPA arrival. LPA checked on 2 residents that relocated and both were in positive moods and had no complaints. The facility had 2 day perishables and 7 day non-perishables to met the food requirements. The facility had toilet paper, paper towels, soap, laundry detergent and cleaning supplies. The facility was clean, safe and sanitary upon inspection.

Community Care Licensing (CCL) requested documents on prior facility for a solvency audit for both facilities due to cancellation of Liability Insurance.
LPA requested the following records: Current Business Bank Statement, Current Facility Mortgage Statement, Current Facility Utilities bills water, trash, PG&E, gas, and telephone to provide to LPA by 4:00 PM today. LPA emailed Licensee the following forms to complete and email back to LPA, LIC. 401, LIC. 401a, LIC. 403, LIC. 403a, and LIC. 404 by 02/20/2023 COB.

Licensee provided an up to date copy of Liability Insurance on 01/03/2023 covering the facility above. Licensee stated the facility is not having any financial difficulties and has funds to keep the operation open and running with proper supplies. The licensee has a personal C-Train with a trailer that had to be moved from property and stored at an alternate location which is a personal issue and does not have anything to do with the Business/Facility.

Exit interview conducted and copy report printed for Licensee/Administrator
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE: DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/16/2023
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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