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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801596
Report Date: 10/09/2025
Date Signed: 10/09/2025 03:08:44 PM

Document Has Been Signed on 10/09/2025 03:08 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/
DIRECTOR:		KARINA RAMIREZ VAZQUEZFACILITY TYPE:
740
ADDRESS:8217 TIARA ST.TELEPHONE:
(805) 659-4603
CITY:VENTURASTATE: CAZIP CODE:
93004
CAPACITY: 6CENSUS: 5DATE:
10/09/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:58 AM
MET WITH:Karina Ramrez VazquezTIME VISIT/
INSPECTION COMPLETED:
03:10 PM
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Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced required Annual Inspection at the above-named facility. LPA was greeted by staff. Administrator Karina Ramirez Vazquez was contacted via telephone and arrived at 10:13AM. LPA explained the purpose of the visit. Entrance interview conducted.

At the time of arrival, there were 5 (five) residents in care and 1 (one) caregiver on duty. The facility accepts residents with a dementia diagnosis; has a hospice care waiver for two (2) residents; and a fire clearance for six (6) non-ambulatory residents. Currently there are no residents on hospice residing in the facility.

The facility is a one-story home located in a residential area. Beginning at 11:08AM, the LPA along with the Administrator toured the facility inside and outside to ensure resident health and safety and the facility is in compliance with Title 22 regulation. Various smoke alarms and carbon monoxide detectors were tested and functioned properly. The fire extinguisher was purchased 09/16/2024 and appeared fully charged.

BEDROOMS: The facility has 4 (four) bedrooms total; 2 (two) are shared resident rooms and 2 (two) are private rooms. All resident bedrooms were observed to be furnished properly. All resident rooms had appropriate bedding. There is an ample supply of linens and towels stored in the cabinets in the hallway.

RESTROOMS: The facility has three (3) full bathrooms for resident and staff use. All restrooms contained grab bars and slip-resistant surfaces. Hot water was measured at 109.8 degrees Fahrenheit, which is within the required range.

COMMON AREAS: Paint, windows, blinds, and floors are in good repair. The common living and dining areas are clean and properly furnished. A working telephone is present. There is one (1) fireplace in the


Report Continued on LIC 809-C
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Kelly Dulek
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/09/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 10/09/2025
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residence, which was properly screened at the time of the visit. Chemicals are stored locked under the kitchen sink and in the locked entry closet.

KITCHEN: The facility has a sufficient supply of non-perishable food, perishable food and an emergency supply of water is present. Knives are stored in a locked cabinet. Cleaning supplies were observed locked in a cabinet under the sink. The refrigerator/freezer was at the appropriate temperature (40*F and 0*F).

OUTDOOR SPACE: Building and grounds are free from hazard. Patio area observed outdoor shaded seating area for resident use. Both outdoor exit gates were observed to be self-closing and self-latching.

RECORD REVIEW: Beginning at 12:00PM (resident files) and 01:20PM (staff files), the LPA began file review. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. All 3 (three) staff files and 5 (five) resident files observed were in compliance with regulation. All trainings were observed to be complete.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: The facility does not currently have an infection control plan. LPA discussed the facility's infection control practices with the Administrator and reviewed the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster plan was observed to be complete and updated annually, as required. Emergency disaster drills are conducted quarterly.

MEDICATION REVIEW: Medications for two (2) residents were reviewed. Medications were observed stored in a locked cabinet. All medications reviewed were properly stored and documented on the Centrally Stored Medication and Destruction Record and appeared to be administered as prescribed.

INTERVIEWS: LPA interviewed staff and residents. No concerns noted.

No citations issued. Exit interview conducted. A copy of today's report was provided.

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Kelly Dulek
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025
LIC809 (FAS) - (06/04)
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