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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801596
Report Date: 07/13/2021
Date Signed: 07/13/2021 12:26:12 PM

Document Has Been Signed on 07/13/2021 12:26 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:
07/13/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:53 AM
MET WITH:KARINA RAMIREZ VAZQUEZTIME COMPLETED:
12:30 PM
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At 9:53 am, Licensing Program Analyst (LPA) Emily Peraldi, conducted an unannounced case management visit. LPA met with caregiver, Antonia Vazquez and explained the reason for visit. Administrator, KARINA RAMIREZ VAZQUEZ arrived at 12:00 pm. Reason for visit was due to Mitigation Plan not being submitted.

LPA collected a copy of the Mitigation Plan for review. At 10:30 am, LPA toured the physical plant area inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations.

At 12:20 pm, exit interview was conducted with Administrator, and a copy will be provided via email. Appeal Rights will be provided via email.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE: DATE: 07/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/13/2021
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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