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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198202435
Report Date: 07/31/2024
Date Signed: 08/02/2024 08:06:44 AM


Document Has Been Signed on 08/02/2024 08:06 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245



FACILITY NAME:MARIPOSA HOUSE (HFL HARBOR GATEWAY HOMES)FACILITY NUMBER:
198202435
ADMINISTRATOR:LIESS, CAROL MFACILITY TYPE:
735
ADDRESS:21218 MARIPOSA AVETELEPHONE:
(310) 781-3045
CITY:TORRANCESTATE: CAZIP CODE:
90502
CAPACITY:6CENSUS: 6DATE:
07/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:41 AM
MET WITH:MANAGER MARIA MUSETIME COMPLETED:
03:00 PM
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
On 07/31/2024 at 11:40 AM, Licensing Program Analyst LPA) Jose Calderon conducted an unannounced annual inspection visit at the Mariposa House Facility. LPA Calderon was allowed entry into the facility by Manager Maria Muse. Manager Muse asked infection control questions and took LPA Calderon temperature prior to entrance into the facility. The facility is licensed to operate for six (6) ambulatory clients between the ages of 18 through 59. Currently, there are six (6) residents residing in the facility, between the age of 18 to 59.

LPA Calderon explained to Manager Muse, the purpose of the one-year Annual Inspection visit, and escorted LPA Calderon on a tour of the entire inside and outside facility grounds. As part of the inspection, LPA Calderon reviewed: Six (6) client service records, six (6) client medication records, two (2) staff records, and inspected the inside facility and outside grounds. LPA Calderon interviewed six (6) clients and two (2) staff members for visit. The facilities’ last fire drill was conducted on 07/29/2024. The one-story residential home consists of three (3) client bedrooms, two (2) client bathrooms, living room, dining room, kitchen, staff room, office area, attached garage with washer and dryer/ storage area, backyard with table and chairs. No weapons are stored in the premises. Kitchen was inspected and observed to be clean and operational. A two-day supply perishable and seven-day supply of non-perishable foods are present in the facility. Emergency Water Storage is in the garage and kitchen area.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:
DATE: 07/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: MARIPOSA HOUSE (HFL HARBOR GATEWAY HOMES)
FACILITY NUMBER: 198202435
VISIT DATE: 07/31/2024
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
During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and clients, sanitizing stations (Located in common areas and restrooms). LPA observed staff and clients were wearing face coverings. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE).

LPA Calderon advised the Manager Muse to continuously monitor the Centers for Disease Control (CDC) website and Community Care Likening Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA Calderon did not observe deficiencies therefore no citations were issued at this time. Annual Licensing Fee is CURRENT. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Manager Maria Muse.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: MARIPOSA HOUSE (HFL HARBOR GATEWAY HOMES)
FACILITY NUMBER: 198202435
VISIT DATE: 07/31/2024
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
LPA Calderon observed that all facility rooms are clean and in good repair. A comfortable temperature was observed, and the facility has central air and heating. LPA Calderon observed the following during inspection of client’s rooms: mattresses are in good condition, adequate lighting present, plenty of dresser/closet space is present, and all bed linens present. All bedrooms contain furniture, lighting fixtures and personal storage space as required, all beds have the required amount of linen and mattress covers, LPA Calderon observed fully stocked closet with bedding, towels, and toiletries supplies. Bathroom fixtures are clean, in good repair, and working properly and contain the required nonskid mats and grab bars. LPA Calderon observed bathrooms were found to be within Title 22 regulation. Bathroom #1 hot water temperature properly measured at 108 degrees Fahrenheit. Bathroom #2 hot water temperature properly measured at 109 degrees Fahrenheit. Kitchen hot water temperature properly measured at 117 degrees Fahrenheit. Facility (2) Carbon Monoxide and (8) Smoke Detectors hard wired and connected were tested and are working properly. The facility three (3) Fire Extinguishers was checked and found to be fully charged and accessible. All exit doors in the facility have alarm systems. All toxins and knifes are locked/secured and inaccessible to clients. Medications are centrally stored and in a locked storage cabinet. Facility one (1) first aid kit is fully stocked with manuals was checked and in order. Outside grounds were toured and no bodies of water were observed. All Exits/ Walkways around the home were free of debris and hazards. Outside patio accessible to clients. Six (6) client files were reviewed and found to be complete. LPA Calderon reviewed six (6) resident medications and they were all found to be administered according to doctor's orders. Two (2) staff files were checked and have the required documents. LPA Calderon noted the Administrator Carol Liess Certification # 6025209735 expiration date of 02/25/2025 was valid at time of visit. The facility does handle client's money/cash resources and a Surety bond is needed. International Fidelity Insurance Company #033279827 for $1000.00 was valid at time of inspection. Commercial General Liability Policy #GAH85536230801 policy period from 08/01/2023 to 08/01/2024 underwritten by Lloyds Insurance Company, coverage 1,000,000/3,000,000 is valid at time of inspection. Administrator Carol Liess to email LPA Calderon a full copy of the commercial insurance policy including all endorsements no later than 08/10/2024. All the required documents are posted in the facility in a clearly visible area.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3