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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405802262
Report Date: 10/02/2024
Date Signed: 10/02/2024 03:57:46 PM

Document Has Been Signed on 10/02/2024 03:57 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:VILLA MARIPOSA SENIOR CAREFACILITY NUMBER:
405802262
ADMINISTRATOR/
DIRECTOR:		MIRIAM SALAMANCAFACILITY TYPE:
740
ADDRESS:130 E BRANCH STREETTELEPHONE:
(805) 619-7325
CITY:NIPOMOSTATE: CAZIP CODE:
93444
CAPACITY: 6CENSUS: 3DATE:
10/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:46 AM
MET WITH:Licensee/Administrators Hans Salamanca and Miriam SalamancaTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Rankin arrived at 8:46 am to conduct a 1-year annual visit to the facility above. LPA met Administrator/Licensee Miriam and Hans Salamanca and explained the purpose of the visit.

A tour of the inside and outside of the facility was conducted with Administrator. The following was inspected and noted during the annual visit:

Physical Plant & Environmental Safety: The facility has 3 bedrooms and 2 bathrooms, currently occupying 3 residents. The facility is clean, safe, and sanitary. LPA was authorized to enter and inspect facility. The facility has smoke and carbon monoxide detectors that were working at time of visit. The lighting and lamps are sufficient for the use of the facility and for resident’s comfort. The showers have non-skid mats present. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The pathways are clear of any obstructions. Disinfectant, cleaning solutions and poisons are inaccessible to residents in care and locked in garage. The facility has sufficient space inside and outside for activities and visiting. The facility has a backyard/side yard and patio for resident use with plenty of shade. The facility has telephone and internet service for resident use.

Operational Requirements: The facility has a current plan of operation. The Facility is operating in compliance with the granted fire clearance. The facility has current liability insurance and expires on 12/31/2024. The facility is approved for a capacity of 6 non-ambulatory and has a current Hospice wavier granted for 2. Facility will be submitting a Hospice Waiver for 3 resident.



Continued 809-C
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE: DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/02/2024
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 12
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: VILLA MARIPOSA SENIOR CARE
FACILITY NUMBER: 405802262
VISIT DATE: 10/02/2024
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Staffing: The facility has two full-time Administrators on staff. Staff records are kept confidential. LPA reviewed 2 staff files for required forms and signatures, Files had 1stAid/CPR, LIC 501 Personnel Applications, LIC. 503 Health screenings with TB results, LIC 508 Criminal Record statements and fingerprint background Clearances, Transfers and Exemptions on file.

Personnel Records & Training: LPA reviewed 2 Administrators files. Files have education/Training for renewal of Administrator Certificates present. Administrator certificate will expire 3/13/25 and proof of administrator submission was supplied for second administrator. Due to CDSS backlog this will take months for her to receive their certificate.

Resident Records & Incident Reports: The facility keeps separate files on each resident confidential. Three files were reviewed for signed Admission Agreements, Medical Assessments, LIC. 602A Physicians Report, ID and Emergency contact forms, Appraisal Needs and Services plans (ANS), TB results, Personal Rights and Pre-Admission appraisals are conducted on perspective residents before accepting them into care. Annual ANS and LIC 602 were done for all residents as of August/September of 2024. The Facility does not handle cash resources for any 3 residents in care. Facility does submit incident reports to the department when required.

Resident Rights Information: All require postings were posted in the common area of the facility. Personal rights, Theft and Loss policy, and Non-discrimination notice. CCL Complaint poster and LTCO poster were posted in the entry area of facility. Internet is provided to residents.

Planned Activities: The facility offers activities to all residents in care. The facility also offers additional activities to include books, magazines, newspapers, television, walks, outside area, and a musician comes weekly. One resident takes weekly outings or visits with an external caregiver. Other residents have family visits weekly. The facility has sufficient space to allow for activities indoors and outdoors.

Continued 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: VILLA MARIPOSA SENIOR CARE
FACILITY NUMBER: 405802262
VISIT DATE: 10/02/2024
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Food Service: The facility handles and prepares food safely. While LPA was at facility 2 meals were observed being prepared and one meal was observed being consumed. The meals were fresh, of good quantity and quality, and residents who were at table at time of visit commented they like the food and finished all of the breakfast meal. The facility has 2-day perishables and 7-day non-perishables to meet the food service requirement. The freezer is kept at 0 degrees and the refrigeration is kept at 40 degrees or lower. All food is covered, stored, and marked appropriately. Food, snacks, and drinks are available when the residents want them. A menu is posted for residents in care. Cleaning solutions and equipment are stored separately than food supply. Kitchen areas are kept clean and free from litter, rodents, vermin, and insects.

Incidental Medical & Dental: Facility provides transportation to medical and dental appointments when needed. Medication is kept in a locked cupboard in locked garage. LPA reviewed medication records with the Centrally Stored Medication Destruct Record and Medication Administrator Record. Doctors’ orders were present. Prescription and PRN Medications labels were not altered, and medications were stored in original containers, LPA advised that some additional precautions be done to further assist in their processes. The facility has a locked box for any refrigerated medications. At 8:47 am LPA was preparing items for start of visit at the kitchen table and noticed medication on kitchen counter left out unsupervised while administrator was assisting resident in another room. At 11:50 LPA was finishing Living room/entry tour and opened a 3 drawer cabinet and found discontinued medication from a previous resident citation given.

Disaster Preparedness: The current emergency disaster forms were present/posted. The facility conducts regular reviews of their needed items for emergencies including PPE needs, working alarms, and pathway clearance. Advised licensee that the review of their emergency items should be documented quarterly to show a “drill” has been done in preparation for an emergency event. Observed on top of refrigerator were 4 large flashlights for emergencies. First aid kit was observed in closet area. The fire extinguishers were charged and last inspected on 10/16/23. Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full facility in an emergency. The facility has an emergency food and water supply. The facility has an emergency binder with all required records present.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: VILLA MARIPOSA SENIOR CARE
FACILITY NUMBER: 405802262
VISIT DATE: 10/02/2024
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Residents with Special Health Needs: The facility does accept dementia residents in care. Items of possible concerned where additional precautions, and addition locks be added was discussed and is being updated by administrator. All items that could pose a danger, such as sharps, were locked or inaccessible to residents in care. The facility does not have delayed egress. The facility has 3 hospice residents in care. Hospice care plans are kept on file and up to date. The facility does not have any current residents on oxygen or Home Health Services. The facility has exiting door alarms.

Exit interview conducted, copy of citation and Appeals rights printed for Administrator.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/02/2024 03:57 PM - It Cannot Be Edited


Created By: Melisa Rankin On 10/02/2024 at 03:30 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: 10/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in that in two instances medication was found on the counter, or in an unlocked cabinet which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/18/2024
Plan of Correction
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Administrator agrees to review regulations regarding medication in section 87465 and provide a statement of understanding. Resident also agreed to provide pictures of new locks on cabinets where medication could potentially be stored.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Melisa Rankin
LICENSING EVALUATOR SIGNATURE:
DATE: 10/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2024


LIC809 (FAS) - (06/04)
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