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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801596
Report Date: 06/25/2021
Date Signed: 06/25/2021 06:46:30 PM

Document Has Been Signed on 06/25/2021 06:46 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:MARIPOSA VALLEY, INC.FACILITY NUMBER:
565801596
ADMINISTRATOR:KARINA RAMIREZ VAZQUEZFACILITY TYPE:
740
ADDRESS:8217 TIARA ST.TELEPHONE:
(805) 659-4603
CITY:VENTURASTATE: CAZIP CODE:
93004
CAPACITY: 6CENSUS: 6DATE:
06/25/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:32 PM
MET WITH:Karina Ramirez VasquezTIME COMPLETED:
06:00 PM
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A physical plant tour was conducted to ensure there are no health and safety hazards. The facility is currently fire cleared for 6 non-ambulatory residents. The facility was observed to be clean, sanitary, and in good repair. Resident restrooms were observed to be clean and sanitary and in working condition. Grab bars were present in the bathrooms. Hygiene items are being provided. LPA observed appropriate and sufficient lighting in each room. LPA observed fire extinguisher fully charged. Smoke and carbon monoxide detectors were tested and operable. LPA observed COVID signs posted in the facility. LPA did not observe a sufficient supply of perishable and non-perishable fruit. Centrally stored medicines are kept in locked closet in the entry way. Outdoor area toured.

During facility tour with Administrator at 4:09 pm LPA observed a water fountain in backyard accessible to residents. During facility tour at 4:19 pm with Administrator LPA observed floor cleaner, detergent, shout stain remover and a tool in the garage accessible to residents. During facility tour at 4:22 pm with Administrator LPA observed all-purpose cleaner, toilet bowl cleaner, dish soap, windex, air freshener, kaboom oxi clean and furniture polish in unlocked kitchen cabinet accessible to residents. During facility tour at 4:23 pm with Administrator LPA observed knives, scissors and lighter in a kitchen drawer accessible to residents. During facility tour at 4:29 pm with Administrator LPA observed medicated body powder, ventolin inhaler, tylenol pill, brimonidine tartrate ophthalmic solution, dorzolamide HCI ophthalmic solution, refresh tears and lumigan opthalmic solution in resident #1 (R1)'s bedroom accessible to residents. During facility tour at 4:33 pm with Administrator LPA observed retin-A cream, voltaren arthritis cream, preparation H and scissors in resident bathroom cabinet accessible to residents. During facility tour at 4:34 pm with Administrator LPA observed muscle cramp and spasm foam in R2 and R3's shared bedroom accessible to residents. During facility tour at 4:35 pm with Administrator LPA observed arthritis pain gel in R4's bedroom accessible to residents. During facility tour at 5:06 pm with Administrator LPA did not observe a sufficient supply of perishable and non-perishable fruit as the facility had 1 large can of pears and 7 apples.

Continued on 809-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Joann Rosales
LICENSING EVALUATOR SIGNATURE: DATE: 06/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/25/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: MARIPOSA VALLEY, INC.
FACILITY NUMBER: 565801596
VISIT DATE: 06/25/2021
NARRATIVE
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Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

Civil penalties assessed in the amount of $500.00

Exit interview conducted, today's reports, civil penalty and appeal rights were reviewed and emailed to the Administrator.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Joann Rosales
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 06/25/2021 06:46 PM - It Cannot Be Edited


Created By: Joann Rosales On 06/25/2021 at 05:13 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: MARIPOSA VALLEY, INC.
FACILITY NUMBER: 565801596

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/25/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/25/2021
Section Cited
CCR
87307(e)

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87307 Personal Accommodations and Services.(e) Facilities providing services to residents who have physical or mental disabilities shall assure the inaccessibility of fishponds, wading pools, hot tubs, swimming pools, or similar bodies of water...through fencing, covering or other means.
This requirement is not met as evidenced by:
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Administrator placed rocks and reduced water level during facility visit. Administrator stated that they will provide documentation of scheduled training with staff regarding regulation 87307(e) by 6/26/21.
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Based on LPA's observation, the licensee did not comply with the section cited above as the facility had a water fountain in the backyard accessible to residents which poses an immediate health and safety risk to persons in care.
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Type A
06/26/2021
Section Cited
CCR87465(h)(2)

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87465 Incidental Medical and Dental Care Services (h)(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:
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Staff placed medication in locked medication cabinet during facility visit. Administrator stated that they will provide documentation of scheduled medication training with staff regarding regulation 87465(h)(2) by 6/26/21.
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Based on LPA's observation, the licensee did not comply with the section cited above as LPA observed medications in R1's bedroom which poses an immediate health and safety risk to persons 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:Kristin Heffernan
LICENSING EVALUATOR NAME:Joann Rosales
LICENSING EVALUATOR SIGNATURE:
DATE: 06/25/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/25/2021


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 06/25/2021 06:46 PM - It Cannot Be Edited


Created By: Joann Rosales On 06/25/2021 at 05:29 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: MARIPOSA VALLEY, INC.
FACILITY NUMBER: 565801596

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/25/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/26/2021
Section Cited
CCR
87705(f)(1)

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87705 Care of Persons with Dementia. (f)(1)The following shall be stored inaccessible to residents with dementia: Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
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Administrator stated that they will provide documentation of items placed in an inaccessible location and scheduled staff training regarding regulation 87705(f)(1) to CCL by 6/26/21.
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Based on LPA’s observations, the licensee failed to ensure that knives, scissors, lighter and a tool were stored inaccessible to residents with dementia which posed an immediate health risk to persons in care.
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Type A
06/26/2021
Section Cited
CCR87705(f)(2)

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Care of Persons with Dementia. The following shall be stored inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
This requirement is not met as evidenced by:
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Staff placed over-the-counter medications in a locked medication cabinet during facility visit. Administrator stated that they will provide documentation of toxic items placed in an inaccessible location and scheduled staff training regarding regulation 87705(f)(2) to CCL by 6/26/21.
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Based on LPA’s observations, the licensee failed to ensure that over-the-counter medications and toxic substances were stored inaccessible to residents with dementia which posed an immediate health risk to persons 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:Kristin Heffernan
LICENSING EVALUATOR NAME:Joann Rosales
LICENSING EVALUATOR SIGNATURE:
DATE: 06/25/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/25/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/25/2021 06:46 PM - It Cannot Be Edited


Created By: Joann Rosales On 06/25/2021 at 05:36 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: MARIPOSA VALLEY, INC.
FACILITY NUMBER: 565801596

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/25/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/29/2021
Section Cited
CCR
87555(b)(26)

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87555 General Food Service Requirements.(b)(26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
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Administrator stated that they will provide documentation of a 2 day supply of perishable and one week supply of nonperishable fruit to CCL by 6/29/21.
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Based on LPA's observations, the licensee did not comply with the section cited above as the facility did not have a 2 day supply of perishable and one week supply of nonperishable fruit which poses a potential health and personal rights risk to persons 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:Kristin Heffernan
LICENSING EVALUATOR NAME:Joann Rosales
LICENSING EVALUATOR SIGNATURE:
DATE: 06/25/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/25/2021


LIC809 (FAS) - (06/04)
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