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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405802262
Report Date: 10/12/2023
Date Signed: 10/12/2023 03:41:21 PM


Document Has Been Signed on 10/12/2023 03:41 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:VILLA MARIPOSA SENIOR CAREFACILITY NUMBER:
405802262
ADMINISTRATOR:MIRIAM SALAMANCAFACILITY TYPE:
740
ADDRESS:130 E BRANCH STREETTELEPHONE:
(805) 619-7642
CITY:NIPOMOSTATE: CAZIP CODE:
93444
CAPACITY:6CENSUS: 3DATE:
10/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Hans & Miriam Salamanca, Administrator/LicenseeTIME COMPLETED:
03:50 PM
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Licensing Program Analyst (LPA) De Leon arrived at 10:45 am to conducted a 1 year annual visit to the facility above. LPA met Administrator/Licensee Miriam and Hans Salamanca and explained the purpose of the visit.

A tour of the inside and outside of the facility was conducted with Administrator. The following was inspected and noted during the annual visit:

Infection Control: The facility has a Infection Control Plan. The facility has a sign in and out binder for visitors at entry. The bathrooms have toilet paper, paper towels, hand soap, and hand washing signs. The facility has EPA approved disinfectants spray and cleaners. The facility has a 30 day supply of PPE. Quarantined or isolated individuals will have meals and medication delivered to rooms. Staff are trained on infection control and the use of Personal Protective Equipment (PPE). All trash cans and waste baskets have tight fitting covers.

Physical Plant & Environmental Safety: The facility is a 3 bedroom and 2 bathroom currently occupying 3 residents and 2 Administrator. The facility is clean, safe and sanitary. LPA was authorized to enter and inspect facility. The facility has smoke and carbon monoxide detectors. The lighting and lamps are sufficient for the use of the facility and for residents comfort. The facility kitchen is clean, safe and sanitary. The showers have non-skid textured floors or mats present. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The pathways are clear of any obstructions. Facility is well lit inside and outside. Disinfectant, cleaning solutions and poisons are inaccessible to residents in care and locked in garage. The facility has sufficient space inside and outside for activities and visiting. The facility has a backyard/side yard and patio for resident use with plenty of shade. The facility has telephone and internet service for resident use. Continued 809-C
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2023
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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: VILLA MARIPOSA SENIOR CARE
FACILITY NUMBER: 405802262
VISIT DATE: 10/12/2023
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Operational Requirements: The facility has a current plan of operation. The Facility is operating in compliance with the granted fire clearance. The facility has current liability insurance and expires on 12/30/2023. The facility is approved for a capacity of 6 Non-Ambulatory and has a current Hospice wavier granted for 2. The facility phone number has been changed and the new phone number is 805-619-7325.

Staffing: The facility has two full-time Administrators on staff. Staff records are kept confidential. LPA reviewed 2 staff files for required forms and signatures, Files had 1stAid/CPR, LIC 501 Personnel Applications, LIC. 503 Health screenings with TB results, LIC 508 Criminal Record statements and fingerprint background Clearances, Transfers and Exemptions on file.

Personnel Records & Training: The facility keeps confidential files for each staff member. LPA reviewed 2 Administrators files. Files have education/Training for renewal of Administrator Certificates present. 1 Administrator certificate expire on 09/22/2024 and 1 Administrator certificate is in the renewal process and was verified pending on Community Care Licensing (CCL)website . Administrator did not have documented Quarterly Drills and will provide records to CCL.

Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Three files were reviewed for signed Admission Agreements, Medical Assessments, LIC. 602A Physicians Report, ID and Emergency contact forms, Appraisal Needs and Services plans (ANS), TB results, Personal Rights and Pre-Admission appraisals are conducted on perspective residents before accepting them into care. The Facility does not handle cash resources for any 3 residents in care. Facility does submit incident reports to the department when required.

Resident Rights Information: All require postings were posted in the common area of the facility. Personal rights, Rights to Resident Council, Theft and Loss policy, and Non-discrimination notice. CCL Complaint poster and LTCO poster were posted in the entry area of facility. The current license along with CCL's last reports is on file. CCL PIN's were posted. Visitation policy is posted at entry. Internet is provided to residents with confidentiality and privacy.

Planned Activities: The facility offers activities to all residents in care. The facility also offers additional activities to include books, magazines, newspapers, television, daily walks, group discussions, and puzzles. The facility has sufficient space to allow for activities indoors and outdoors. Continued 809-C
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: VILLA MARIPOSA SENIOR CARE
FACILITY NUMBER: 405802262
VISIT DATE: 10/12/2023
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Food Service: The facility handles and prepares food safely. The facility has 2 day perishables and 7 day non-perishables to meet the food service requirement. The freezer is kept at 0 degrees and the refrigeration is kept at 40 degrees or lower. All food is covered, stored and marked appropriately. Food, snacks and drinks are available when the residents want them. Emergency supply of food and water is available. A menu is posted for residents in care. Cleaning solutions and equipment are stored separately than food supply. Kitchen areas are kept clean and free from litter, rodents, vermin and insects. Kitchen staff are observed for personal hygiene and food sanitation practices.

Incidental Medical & Dental: Facility provides transportation to medical and dental appointments when needed. Medication are kept in a locked cupboard in locked garage. LPA reviewed medication records with the Centrally Stored Medication Destruct Record and Medication Administrator Record. Doctors orders were present. Prescription and PRN Medications labels were not altered and medications were stored in original containers and no medications were expired. The facility has a locked box for any refrigerated medications.

Disaster Preparedness: The current emergency disaster forms were present/posted. The facility conducts quarterly disaster drills. The fire extinguishers were charged and inspected. Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full facility in an emergency. The facility has an emergency food and water supply. The facility has an emergency binder with all required records present.

Residents with Special Health Needs: The facility does accept dementia residents in care. All items that could pose a danger, sharps, cleaners were locked or in accessible to residents in care. The facility does not have delayed egress. The facility has 2 hospice residents in care. Hospice care plans are kept on file and up to date. The facility does not have any current residents on oxygen or Home Health Services. The facility has exiting door alarms.

LPA conducted interviews with 2 Staff and 2 residents.

Exit interview conducted and copy of report printed for Administrator.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5