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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405802262
Report Date: 09/15/2023
Date Signed: 09/15/2023 02:58:24 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/14/2023 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20230914111545
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: 3DATE:
09/15/2023
UNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Herbert "Hans" Salamanca, Licensee/AdministratorTIME COMPLETED:
03:10 PM
ALLEGATION(S):
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Staff left residents alone at the facility for an extended amount of time.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) De Leon conducted a 10-day complaint visit to the facility above. LPA met with Herbert Salamanca Licensee/Administrator of the facility and explained the purpose of the visit.

LPA requested a staff roster with telephone numbers, a resident roster, 3 residents ID and emergency information forms and 3 residents physicians report (LIC 602A). Licensee/Administrator provided all documentation requested.

At 1:15pm LPA toured the facility to check on the welfare of the 3 residents in care.

On 09/15/2023 LPA interviewed Witness at 9:40am, Licensee/Administrator at 1:00pm, and residents at 1:20pm and 1:30pm.

Continued 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 29-AS-20230914111545
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/15/2023
NARRATIVE
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On the allegation: Staff left residents alone at the facility for an extended amount of time. LPA conducted interviews with Witness which revealed on 09/13/2023 upon arrival about 1:08pm the facility did not have any staff present for a period of 45 minutes to 1 hour leaving 3 residents at the facility alone without supervision and staff returned to the facility around 1:50pm. LPA's interview with Licensee/Administrator revealed residents were left alone around 1:00pm after lunch Administrator went to CVS pharmacy to pick up resident medications then to a convenient store about a block and a half away from the facility to pick up a grocery item needed for dinner. Licensee/Administrator felt it was a bad judgment and was gone for only 15-20 minutes total. LPA interviewed residents which revealed 2 of 3 residents remembering being left alone, not sure of the exact date, it was a few days ago and the residents think it was for over 1 hour or so but more than 15-20 minutes.

LPA reviewed 3 residents LIC. 602A Physicians Report according to those reports the facility has residents diagnosed with dementia, a resident on hospice services, a resident requiring 24/7 supervision, and a resident that can not leave the facility unassisted. Based on the evidence this allegation is Substantiated at this time.

Exit interview conducted, deficiency cited, civil penalty assessed, copy of report and appeal rights printed for Licensee/Administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20230914111545
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/18/2023
Section Cited
CCR
87464(f)(1)
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(f)Basic services shall at a minimum include:(1)Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by:
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Licensee agreed to review regulation 87464, write a statement of understanding on how the facility will prevent this from occurring again, provide an LIC 500 for staff, submit an incident report to the CCL and notify all residents responsible parties of the incident.
Civil Penalty Assessed.
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Based on interviews, the licensee did not comply with the regulation above 3 residents were left alone without care and supervision for up to an hour which posed an immediate Health, Safety and Personal Rights 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.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3