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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275202497
Report Date: 01/28/2022
Date Signed: 01/31/2022 09:45:31 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
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: 7DATE:
01/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Gabriella EspinozaTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Marybeth Donovan conducted an unannounced Required - 1 Year Annual Inspection to include Infection Control site visit and met with Gabriella Espinoza Supervisor.

LPA toured the facility inside and out. All fire exit routes were free and clear of obstructions. LPA observed a supply of PPEs. These supplies are inventoried and restocked regularly.

Facility observed to have designated entry point for COVID 19 symptom screening and temperature check. Bathrooms observed to be supplied with hygiene products and hand washing signs posted. Hand sanitizer stations placed throughout the facility. Postings included Visitor Policy, COVID 19 Symptom & Warning Signs, Use Caution, Cough Etiquette, Prevent the Spread and Social Distancing..

LPA reviewed the facility policies and procedures to include screening, visitation, isolation, disinfecting, sick leave polices, training, PPE usage and N95 Fit Testing.

No citations issued per the California Code of Regulations Tittle 22.

LPA reviewed report with Gabriella Espinoza Supervisor and a copy of this report provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2022
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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