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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405802262
Report Date: 10/07/2026
Date Signed: 10/07/2026 04:59:02 PM

Document Has Been Signed on 10/07/2026 04:59 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:VILLA MARIPOSA SENIOR CAREFACILITY NUMBER:
405802262
ADMINISTRATOR/
DIRECTOR:		MIRIAM SALAMANCAFACILITY TYPE:
740
ADDRESS:130 E Branch STTELEPHONE:
(805) 619-7325
CITY:NipomoSTATE: CAZIP CODE:
93444
CAPACITY: 6CENSUS: 2DATE:
10/07/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:34 PM
MET WITH:Caregiver, Miriam SalamancaTIME VISIT/
INSPECTION COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Rankin arrived at 12:34 am to conduct a 1-year annual visit to the facility above. LPA met with caregiver. LPA was able to speak via the phone with the Administrator/Licensee Herbert Salamanca. Administrators are out of town on a family emergency, LPA met with a background cleared staff member to review findings.

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

Physical Plant & Environmental Safety: The facility has 3 bedrooms and 2 bathrooms, currently occupying 2 residents. The facility for most areas were clean, but the bathroom facilities had feces on the toilet, LPA noted that the water heater does not have earthquake straps, both straps were hanging on the wall, but not around the water heater, citation given. The facility has smoke and carbon monoxide detectors that were tested and working at time of visit. The lighting and lamps are sufficient for the use of the facility and for residents’ comfort and safety. The showers have non-skid mats present. Toilet, hand washing and bathing facilities are operational and secure grab bars are present. The indoor pathways are clear of any obstructions. The facility has sufficient space inside and outside for activities and visiting. The facility has a backyard/side yard and patio for residents; there is plenty of shade on the front porch. Disinfectants, cleaning solutions and hygiene items were accessible to clients in care, they were found in unlocked cabinets and unlocked closet, as well as items on the night stand next to each resident bed. A citation was given regarding accessibility to cleaning chemicals, hygiene products, medication, and knives.

Operational Requirements: The Facility is operating in compliance with the granted fire clearance. The facility has current liability insurance and expires on 9/2/2027. The facility is approved for a capacity of 6 non-ambulatory of which 2 can be bedridden and has a current Hospice wavier granted for 3.


Continued 809-C
Kelly Burley
Melisa Rankin
DATE: 10/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 10/07/2026 04:59 PM - It Cannot Be Edited


Created By: Melisa Rankin On 10/07/2026 at 01:53 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VILLA MARIPOSA SENIOR CARE
FACILITY NUMBER: 405802262

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type B
Section Cited
CCR
87205(b)
(b) If the licensee is a corporation or an association, the governing body shall be active, and functioning in order to assure accountability.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above when LPA researched on California Secretary of State and found the status of the licensee VILLA MARIPOSA SENIOR, LLC to be "suspended-FTB" as of 4/2/2024 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/23/2026
Plan of Correction
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Licensee stated they will contact the Secretary of State and Franchise Tax Board to find out how to come into compliance and work to bring the LLC back into good standing by 10/23/2026. Licensee will email LPA on or before 10/23/2026 with status of the LLC.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kelly Burley
NAME OF LICENSING PROGRAM MANAGER:
Melisa Rankin
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/07/2026 04:59 PM - It Cannot Be Edited


Created By: Melisa Rankin On 10/07/2026 at 03:55 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VILLA MARIPOSA SENIOR CARE
FACILITY NUMBER: 405802262

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above when Staff 1 (S1) was found not to be on the Facility Background Clearance records which poses an immediate health and safety risk to persons in care.
POC Due Date: 10/08/2026
Plan of Correction
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Licensee will ensure that all staff, volunteers and anyone who requires a criminal record clearance is cleared and associated PRIOR to being present at the facility. Licensee will either associate the staff via Guardian or submit an LIC9182 with a legible copy of a government identification to request the criminal background clearance to have Staff 1 associated to the facility.
Type A
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above when 2 out of 2 staff on site covering the facility did not have a First Aid Certificate which poses an immediate health, safety and personal rights risk to persons in care.
POC Due Date: 10/09/2026
Plan of Correction
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LPA requested that staff on duty complete first aid certificate training and submit to LPA by the close of 10/9/26.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kelly Burley
NAME OF LICENSING PROGRAM MANAGER:
Melisa Rankin
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2026


LIC809 (FAS) - (06/04)
Page: 3 of 11
Document Has Been Signed on 10/07/2026 04:59 PM - It Cannot Be Edited


Created By: Melisa Rankin On 10/07/2026 at 03:55 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VILLA MARIPOSA SENIOR CARE
FACILITY NUMBER: 405802262

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the toilet contained feces along the rim, and the earthquake straps were removed from the water heater which poses a potential health, safety risk to persons in care.
POC Due Date: 10/16/2026
Plan of Correction
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The licensee will clean up and maintain sanitary / infection care practices with areas where bodily fluids are found and areas that are unsafe, such as the earthquake straps be reattached. Proof of earthquake straps will be submitted by 10/16/26.
Type B
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above when LPA found Medications, hygiene products, cleaning products, knife drawer unlocked and accessible to residents who have dementia which poses a potential health, safety risk to persons in care.
POC Due Date: 10/09/2026
Plan of Correction
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LPA requested that all items be removed from drawers that cannot be locked, that items be moved to areas that are inaccessible, and doors that can be locked be locked.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kelly Burley
NAME OF LICENSING PROGRAM MANAGER:
Melisa Rankin
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2026


LIC809 (FAS) - (06/04)
Page: 4 of 11
Document Has Been Signed on 10/07/2026 04:59 PM - It Cannot Be Edited


Created By: Melisa Rankin On 10/07/2026 at 03:55 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VILLA MARIPOSA SENIOR CARE
FACILITY NUMBER: 405802262

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(h)(1)
Reappraisals
(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. (1) Documentation of the annual routine visit, such as a visit summary, shall be added to the resident's record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review the licensee did not comply with the section cited above when 2 our of 2 residents in care do not have documentation to show their current medical visits which poses a potential health, safety and personal rights risk to persons in care.
POC Due Date: 10/30/2026
Plan of Correction
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LPA requests that licensee contact physician to complete an updated medical assessment and documents must be submitted to LPA via email by 10/30/26. Documentation must also be filed in current resident records.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kelly Burley
NAME OF LICENSING PROGRAM MANAGER:
Melisa Rankin
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2026


LIC809 (FAS) - (06/04)
Page: 5 of 11
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: VILLA MARIPOSA SENIOR CARE
FACILITY NUMBER: 405802262
VISIT DATE: 10/07/2026
NARRATIVE
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Staff Personnel Records & Training: The facility has two full-time Administrators on staff and one background cleared staff who was present at the end of the visit. Another staff was present when LPA arrived, a review of background clearance provided the staff member is not background cleared. Administrator and Licensee were confirmed away from the facility and those present did not have current 1st Aid and CPR certification, citation given.

Resident Records & Incident Reports: Residents are the same as last year. LPA reviewed the 2 files for updated Medical Assessments, LIC. 602A Physicians Report, current ID and Emergency contact forms, and Appraisal Needs and Services plans (ANS). Annual ANS report were done for all residents dated for August and September of 2026. Facility did not have documentation of the annual routine visit, in the resident's record, the last medical assessment/physician report found were from 2024, citation given.

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.

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. All food is covered, stored, and marked appropriately. Food, snacks, and drinks are available when the residents want them. Cleaning solutions and equipment are stored separately than food supply. Kitchen areas are kept clean and free from litter and insects.

Disaster Preparedness: The current emergency disaster forms were present/posted. Observed on top of refrigerator were 4 large flashlights for emergencies. First aid kit was observed in closet area. Emergency exits and telephone numbers were posted. The facility has an emergency food and water supply. The facility has an emergency binder with all required records present.

LPA will return at a later date to meet with administrator/licensee and to complete annual inspection.

Exit interview could not be conducted, no designated signer was on grounds and staff were focused on the care and supervision of residents in care. Copies of appeal rights and reports were printed and left for the Administrator.
NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Melisa Rankin
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2026
LIC809 (FAS) - (06/04)
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