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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603777
Report Date: 08/20/2024
Date Signed: 08/20/2024 02:34:44 PM


Document Has Been Signed on 08/20/2024 02:34 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:MARIPOSA MANORFACILITY NUMBER:
374603777
ADMINISTRATOR:WELKER, KELLYFACILITY TYPE:
740
ADDRESS:2525 REED ROADTELEPHONE:
(760) 294-7011
CITY:ESCONDIDOSTATE: CAZIP CODE:
92027
CAPACITY:6CENSUS: 5DATE:
08/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Garrett Welker, Caregiver TIME COMPLETED:
12:15 PM
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On 08/20/24 at 9:20 am Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility for the purpose of conducting a 1 year required visit. LPA was greeted and granted entry by caregiver Dalia Calderon-Cruz where LPA explained the purpose of the visit. LPA met with Caregiver Garrett Welker who arrived at 10:27am.

The facility has an approved hospice waiver for (4), with a total of (4) residents that are currently receiving hospice services. The facility has an approved infection control plan on file as of 05/25/21. Below are the observations made during today's visit:

Physical Plant: LPA toured the interior and exterior areas of the facility and observed that there a sufficient bedrooms and bathrooms for both staff and residents. The facility was observed to have the required furniture and linen to be present and in good condition in resident bedrooms. There are no pools or bodies of water on the premises. LPA observed for the required postings (facility sketch, resident rights, CCL complaint poster, LTCO poster) to be in walkway upon entry.

Staff Records: LPA observed that there are sufficient staff present to meet the needs of residents. LPA George additionally confirmed that there is an Administrator present, the administrator certificate expires on 01/27/25. LPA George confirmed staff have criminal record clearance and were associated to the facility and have training to perform their required duties, which includes valid First Aid Certification. The facility has a Resident # 5 (R5) that is considered independent, upon review of the facility personnel roster, LPA observed for R5 to not be associated to the facility, the facility does not have Guardian access but will take the necessary steps to have R5 associated, by 5pm on Friday 08/23/24. LPA verified that R5 has obtained the proper criminal record clearance. Per staff R5 was on the roster and somehow fell off.

Resident Records: A review of resident files was conducted and were observed to have the required information present in their files, including Physician's Report, Admissions Agreement, and current Needs & Services Plan or assessments.

SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: MARIPOSA MANOR
FACILITY NUMBER: 374603777
VISIT DATE: 08/20/2024
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Food Services: The kitchen and dining area to be maintained in a clean and healthful manner. LPA George observed the facility to have the required amount of 7 day supply non-perishable and a two supply perishable food items.

Medication: Resident medication was observed to be locked inside a medication cart, However while LPA toured the kitchen LPA observed for there to be a bubble pack of medication belonging to a resident that was no longer at the facility to be sitting on top of the refrigerator. The medications were destroyed during today's visit. LPA observed for there to be (1) resident walking around the facility, that could have accessed the medication. Technical violation (TV) issued.

Emergency Disaster Preparedness: The facility has an Emergency Disaster Plan on file and conducts regular disaster drills on a quarterly basis. The last drill was conducted on 07/25/24. The smoke and carbon monoxide detectors were tested and were found to be operable. The facility has fully charged fire extinguisher. There are no known guns or ammunition on the premises. The hot water was tested and was found to be within regulatory limits.

Prior to conducting today's inspection LPA completed a file review on 08/01/24, and found for the facility's annual fees to not have been paid, as they were due on 08/08/24. During today's visit LPA followed up and was informed that the payment was mailed off on or around 08/01/24.

An exit interview was conducted and a copy of this report, LIC811-confidential names list and TV were provided to Caregiver Garrett Welker.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024
LIC809 (FAS) - (06/04)
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