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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275202497
Report Date: 01/05/2021
Date Signed: 01/05/2021 01:37:36 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:MARIPOSA ASSISTED LIVINGFACILITY NUMBER:
275202497
ADMINISTRATOR:MARIA ELENA VALENCIAFACILITY TYPE:
740
ADDRESS:1201 LA SALLE AVE.TELEPHONE:
(831) 345-8560
CITY:SEASIDESTATE: CAZIP CODE:
93955
CAPACITY:15CENSUS: 9DATE:
01/05/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Gabriella Espinoza, Assistant SupervisorTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Jackie Jin and California Department of Public Health HFEN Nurse conducted a tele-visit via FaceTIme to provide technical assistances to prevent and mitigate the spread of COVID-19. LPA met with Gabriella Espinoza, Assistant Supervisor.

During today's tele-visit, the following recommendations were made to the facility:
  2. Post PPE posting on how to put on and take off PPE in the isolation area.
  4. Trash bin with lid in all resident bedrooms and bathrooms.
  6. Ensure furniture are placed to practice social distancing in the common areas and patio area.
  8. Post hand washing poster in the kitchen area by the sink.
  10. Place paper towels in all resident bathrooms.
  12. Remove all hand towels in the resident bathrooms and in common bathrooms.

This report was reviewed with Gabriella Espinoza, Assistant Supervisor of and a copy of this report will be emailed to Gabriella Espinoza, Assistant Supervisor on 01/05/2021 for signature.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR SIGNATURE:

DATE: 01/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2021
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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