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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608746
Report Date: 02/02/2022
Date Signed: 02/02/2022 01:19:56 PM

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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:MARIPOSA RESIDENTIAL CAREFACILITY NUMBER:
197608746
ADMINISTRATOR:MARLON ARSENALFACILITY TYPE:
740
ADDRESS:3434 TAMARISK DRIVETELEPHONE:
(661) 266-4835
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY:6CENSUS: 4DATE:
02/02/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Mary Ann De LimaTIME COMPLETED:
01:00 PM
NARRATIVE
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During LPA's unannounced visit regarding Complaint 31-AS-20210914135606, LPA conducted a tour of the facility. LPA and Caregiver, Pablito Cruz toured the master bedroom which is occupied by a married couple. Upon entering the bathroom, LPA observed there were cleaning supplies in the bathroom. Upon viewing the resident files, LPA observed the TB test results were missing from residents R1 and R2. Pursuant to Title 22 Division 6 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D).

Exit interview conducted, Appeal Rights discussed, and a copy of the report was issued to the Caregiver.

SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:

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

DATE: 02/02/2022
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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MARIPOSA RESIDENTIAL CARE
FACILITY NUMBER: 197608746
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/03/2022
Section Cited

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The following items shall be made 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. LPA observed cleaning supplies in unlocked cabinet under the kitchen sink
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Based on LPA's observations while conducting a tour of the facility, the licensee did not comply with the section cites above as cleaning supplies such as bleach wipes were observed accessible to residents which posed an immediate health risk to persons in care.
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Type B
02/14/2022
Section Cited

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The medical assessment, at a minimum, shall include: A physical exam of the resident containing a primary and secondary diagnosis, if any, results of a test for tuberculosis and any medical conditions which would preclude care of the person in an RCFE. This requirement is not met as evidenced by.
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Based on record review of resident files, R1 and R2 did not contain TB test results. This poses immediate health risk and violation of personal rights to residents 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: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2