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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601381
Report Date: 04/25/2024
Date Signed: 04/25/2024 02:01:07 PM

Document Has Been Signed on 04/25/2024 02:01 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:MARIPOSA HOMEFACILITY NUMBER:
198601381
ADMINISTRATOR/
DIRECTOR:		SUZARA, ZENAIDAFACILITY TYPE:
735
ADDRESS:122 S. MARIPOSA AVE.TELEPHONE:
(213) 674-7129
CITY:LOS ANGELESSTATE: CAZIP CODE:
90004
CAPACITY: 5CENSUS: 3DATE:
04/25/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:Oluwaseun "Patricia" OloyedeTIME VISIT/
INSPECTION COMPLETED:
01:45 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
Licensing Program Analyst (LPA) Alma Gonzalez conducted a case management visit for the death of Client 1 (C1) which occurred on 07/30/23.

LPA made an initial visit on 08/28/23. LPA reviewed death certificate and the death certificate indicates that the immediate cause of death for C1 was Sudden Cardiopulmonary Arrest and Epilepsy. A Biopsy was not performed. An autopsy was not performed. Other Significant Conditions contributing to death were listed as Hypothyroid and Developmental Delay. Place of Death: Mariposa Home 122 S Mariposa Ave., Los Angeles 90004.

Based on the available information reviewed, LPA did not note any deficiencies in reference to C1's death.

Exit interview conducted and copy of report was provided to Administrator Oluwaseun "Patricia" Oloyede.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Alma Gonzalez
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2024
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 1