<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565801596
Report Date: 02/17/2022
Date Signed: 02/25/2022 12:53:17 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
11/09/2020 and conducted by Evaluator Kasandra Lopez
COMPLAINT CONTROL NUMBER: 29-AS-20201109165039
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:
02/17/2022
UNANNOUNCEDTIME BEGAN:
10:31 AM
MET WITH:Antonia VasquezTIME COMPLETED:
11:15 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff caused injury to resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) KaSandra Lopez conducted a subsequent complaint investigation to the above facility. The purpose of the visit is to deliver findings for the above allegation. The initial visit was conducted by LPA on 11/10/2020. During today’s visit, LPA Lopez met with caregiver Antonia Vasquez. Entrance interview conducted. Administrator Karina Ramirez Vasquez was contacted and advised of the visit.

During the initial 10-day virtual inspection on 11/10/2020, the LPA conducted a physical plant tour with the Administrator Karina Ramirez Vazquez beginning at 3:53 PM, attempted to conduct a FaceTime interview with Resident #1 (R1) at 4:00 PM, and conducted an interview with the Administrator. In addition, LPA requested pertinent records and video camera footage to be emailed to the LPA.

Report continued on LIC 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2022
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-20201109165039
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: MARIPOSA VALLEY, INC.
FACILITY NUMBER: 565801596
VISIT DATE: 02/17/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The allegation alleges Staff #1 (S1) grabbed R1’s left arm and wrist and pulled R1 away from a counter causing the resident to fall and sustain a skin tear. The interview with the Administrator revealed she started to have concerns when residents in the home were having unexplained bruising. Although they had cameras in the home, the footage was only a live feed and was not being stored. The Administrator stated she decided to install a memory card so she could store the video footage. When another staff observed an injury to R1’s arm, the Administrator reviewed the video footage which showed S1 grabbing the resident aggressively from the kitchen counter for no reason; causing the resident to fall to the ground and sustain a skin tear to their arm. The Administrator stated they terminated S1 immediately and called law enforcement. The LPA reviewed the video footage provided which revealed on 11/03/2020 at 21:53, R1 was observed to be alone standing at the kitchen counter moving around what appears to be a plastic bag. S1 entered the kitchen and grabbed R1 by both arms, forcefully moving the resident away from the counter causing the resident to fall.

During today's inspection the LPA spoke with the Administrator on the telephone and she said the criminal case is still pending with S1.

Based on the information obtained, there is sufficient evidence to support the allegation occurred. Therefore, the allegation is substantiated at this time. Pursuant to Title 22 CA Code of Regulations, the following deficiency was cited and civil penalty was assessed (refer to LIC 9099-D).

Exit interview conducted and report and civil penalty assessment was reviewed with the Administrator over the telephone. The Administrator gave permission for the caregiver to sign the report. A copy of the report will be emailed.

During today's inspection, the LPA conducted a physical plant tour of the facility and did not observed any immediate health or safety concerns.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20201109165039
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: MARIPOSA VALLEY, INC.
FACILITY NUMBER: 565801596
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/17/2022
Section Cited
CCR
87468.1
1
2
3
4
5
6
7
87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
The Administrator terminated the staff immediately and contacted law enforcement after having knowledge of the incident. Plan of correction is cleared.
8
9
10
11
12
13
14
Based on interviews and observation of video footage, the licensee did not comply with the section cited above as Staff #1 grabbed R1 aggressively causing R1 to fall and sustain a skin tear which poses an immediate health, safety, and personal rights risk to residents in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3