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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608746
Report Date: 04/08/2022
Date Signed: 04/08/2022 03:22:21 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., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/14/2021 and conducted by Evaluator Melissa Spaeth
COMPLAINT CONTROL NUMBER: 31-AS-20210914135606
FACILITY NAME:MARIPOSA RESIDENTIAL CAREFACILITY NUMBER:
197608746
ADMINISTRATOR:MARLON ARSENALFACILITY TYPE:
740
ADDRESS:3434 TAMARISK DRIVETELEPHONE:
(310) 795-2158
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY:6CENSUS: 3DATE:
04/08/2022
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Mary Ann De LimaTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Facility did not notify responsible party of injury
Facility did not seek medical care for resident
INVESTIGATION FINDINGS:
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LPA Spaeth made an unannounced visit and was greeted by Mary Ann De Lima. LPA explained the purpose of the visit was to present LPA’s findings regarding the complaint which alleged staff did not supervise resident resulting in unexplained injuries, facility did not notify responsible party of injury in a timely manner, and facility did not seek medical care for resident in a timely manner.

LPA's temperature was taken, COVID questions answered, and LPA observed the sign in station upon entering the facility. LPA conducted a physical plant tour to ensure no immediate health and safety issues. LPA did not observe any immediate health and safety issues.

LPA Spaeth interviewed the Administrator Madolores Rodriguez,on 3/28/2022 at 11:00 am. Administrator received the call from S1 regarding the fall the night of August 30, 2021. Administrator asked S1 if 911 should be called and S1 stated R1 was ok and probably should not call 911. S1 reported there was a wound over R1's eye but S1 had administered first aid by treating the head wound and applied a bandage on the wound.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022
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 4
Control Number 31-AS-20210914135606
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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: MARIPOSA RESIDENTIAL CARE
FACILITY NUMBER: 197608746
VISIT DATE: 04/08/2022
NARRATIVE
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Administrator stated did not call the family members because it was 9:00 pm California time and Administrator decided would call the family the next morning. Administrator stated did not feel it was an extreme emergency and the family members are there every day. Administrator stated when Administrator called the facility the next morning, the family was there and was upset. The allegation, facility did not notify responsible party of injury is substantiated.

Facility did not seek medical care for resident.

During LPA’s interview with Administrator Madolores Rodriguez, on 3/28/2022, Administrator stated S1 asked R1 if R1 was in pain and R1 said no. S1 reported there was a wound over R1's eye but S1 had administered first aid. Administrator stated did not instruct S1 to call 911 because first aid had been applied and R1 stated was not in pain.

LPA Spaeth spoke to a family member on 1/31/2022 at 3:30 pm who stated received a call on 8/31/2021 from a family friend who stated was at the facility and observed R1 had a head wound, black eye and a wound on R1’s elbow. Family friend asked S1 what happened and was told R1 had fallen. The family member immediately went to the facility, saw the wound on R1’s head, black eye and wound on R1’s elbow. The family member immediately called 911. On 1/31/2022, LPA received photos of R1’s wounds. LPA Spaeth also obtained the hospital records which stated R1 was hospitalized on August 31, 2021 and the medical report notes R1's injuries. Therefore, allegation, facility did not seek medical care for resident is substantiated.

Based upon the evidence received and interviews of the Administrator and family members, the above allegations are substantiated. Pursuant to Title 22 Division 6 of the CA Code of Regulations, a deficiency was cited (refer to LIC 809-D).



Exit interview conducted, Appeal Rights discussed, and a copy of the signed report was issued to Administrator.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 31-AS-20210914135606
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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MARIPOSA RESIDENTIAL CARE
FACILITY NUMBER: 197608746
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/14/2022
Section Cited
CCR
87465(g)
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The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement is not met as evidenced by:
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Administrator will conduct training regarding the care and supervision of residents. Administrator will provide a copy of the sign in sheet stating the names of the staff members who participated in the training.
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Based on family members & Administrator's interview, the facilty staff failed to call 9-1-1 after the fall of R1 which resulted in R1's injuries, which poses an immediate health, safety, and personal rights risk to residents in care.
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Type B
04/08/2022
Section Cited
CCR
87466
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The licensee shall ensure that residents are regularly observed for changes in physical, ..functioning & ...assistance is provided ...When changes such as... physical health condition are observed, the licensee shall ensure that such changes are ...brought to the attention of the resident's physician & resident's responsible person, if any.
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Administrator created a Vitals chart for caregivers to complete on a daily basis and has explained the reason for this daily chart log. Administrator has communicated to all caregivers staff must inform family members when there are any changes in the residents'
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This requirement is not met as evidenced by: Based on interviews with family members & the Administrator, facility staff failed to contact the family members regarding R1's fall and injuries which poses an immediate health, safety, and personal rights risk to residents in care.
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health condition or for any incident. LPA observed the recording logs for each resident and observed daily notes are recorded in the log.
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: 04/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
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., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/14/2021 and conducted by Evaluator Melissa Spaeth
COMPLAINT CONTROL NUMBER: 31-AS-20210914135606

FACILITY NAME:MARIPOSA RESIDENTIAL CAREFACILITY NUMBER:
197608746
ADMINISTRATOR:MARLON ARSENALFACILITY TYPE:
740
ADDRESS:3434 TAMARISK DRIVETELEPHONE:
(310) 795-2158
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY:6CENSUS: 3DATE:
04/08/2022
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Mary Ann De LimaTIME COMPLETED:
02:30 PM
ALLEGATION(S):
1
2
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Staff did not supervise resident resulting in unexplained injuries.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Spaeth conducted an unannounced visit to this facilty in response to the above allegation. LPA was greeted by Administrator, Mary Ann De Lima upon arrival and explained the purpose of today's visit.

LPA Spaeth interviewed Administrator Madolores Rodriguez at 11:00 am on 3/28/2022. Administrator stated was out of town but staff member (S1) called Administrator the night of the accident, August 30, 2021 and stated R1 had fallen, had a laceration near eye, and S1 applied first aid by treating the wound. S1 told Administrator that around 7:35 pm, S1 heard the alarm indicating a resident had fallen and S1 went immediately to R1’s room, found resident on the floor. LPA Spaeth received an unusual incident report which confirmed S1’s description of the incident. LPA was informed S1 no longer works at the facility. LPA called S1 on 3/28/2022 at 1:15 pm; however S1 stated no longer works for the facility and does not remember what happened on August 30, 2022. Based upon Administrator’s interview and the incident report received by LPA, this allegation is unsubstantiated. Also, based upon the information provided, the staff member instantly responded to R1's alarm.

Exit interview conducted, appeal righs discussed, and a copy of the signed report was issued to the Administrator
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4