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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801596
Report Date: 10/07/2021
Date Signed: 10/21/2021 05:03:16 PM

Document Has Been Signed on 10/21/2021 05:03 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:
10/07/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:27 PM
MET WITH:Vega VasquezTIME COMPLETED:
03:45 PM
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Licensing Program Analysts (LPA) Angel Ascencio arrived at the facility unannounced to conduct a required annual visit at 2:27 p.m. This annual had a specific emphasis on infection control practices and procedures. The LPA met with staff Vega Vasquez and discussed the reason for the visit. Entrance interview conducted.

The LPA, along with staff, toured the physical plant areas inside and outside at 3:00 p.m. to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations.

BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 4 (four) total bedrooms for resident use – 2 (two) are shared rooms and 2 (two) are private rooms.

RESTROOMS: Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. LPA observed sufficient amounts of soap and paper products in each restroom, as well as hand washing posters.

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, common seating area and dining room furniture was observed to be in good condition. Chairs were observed to be at least 6 (six) feet apart for social distancing. The LPA observed the required postings in the common hallway. Fire extinguishers were observed to be serviced within the last year.

Continued - LIC 809

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE: DATE: 10/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/08/2021
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: 10/07/2021
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The backyard has a covered outdoor area equipped with furniture for resident use. There were no bodies of water noted. Laundry room contains a locked storage cabinet for laundry supplies. The garage was observed locked and contained the emergency food supply. Medication closet was observed to be locked and contained at least 30 day supply.

KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All knives and cleaning supplies were observed to be locked and properly stored at the time of the visit.

INFECTION CONTROL: During today’s visit, the LPA spoke with staff member regarding the facility’s infection control practices at 3:20 p.m. There are 1 entry into the facility. Upon entry, the facility has a central entry point for symptom screening. The facility is allowing visitors, however LPA noted that the facility is allowing visitors in both indoor and outdoor space. The LPA observed an adequate supply of Personal Protective Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility has not had a confirmed case of COVID-19 at this time.

The following recommendations were made:



- Post PINs and educate staff, residents, and families on changing policies and procedures from the Department

No citations were issued during today’s visit. Exit interview conducted. A copy of the report was provided via email.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021
LIC809 (FAS) - (06/04)
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