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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425802106
Report Date: 02/15/2022
Date Signed: 02/15/2022 02:11:31 PM


Document Has Been Signed on 02/15/2022 02:11 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:MARIPOSA AT ELLWOOD SHORESFACILITY NUMBER:
425802106
ADMINISTRATOR:PETER JOHN BONILLAFACILITY TYPE:
740
ADDRESS:190 VIAJERO DRTELEPHONE:
(805) 265-4327
CITY:GOLETASTATE: CAZIP CODE:
93117
CAPACITY:99CENSUS: 90DATE:
02/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Peter BonillaTIME COMPLETED:
02:15 PM
NARRATIVE
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On 02/15/22 at 9:00 a.m., Licensing Program Analyst (LPA) Toan Luong conducted an unannounced One Year Infection Control Annual visit to the facility. LPA met with Administrator Peter Bonilla and explained the purpose of the visit.

LPA was screened at the entrance, and LPA toured of the the residential care facility for the elderly. At 9:45 a.m., LPA discussed items in the Infection Control Module and noted that facility has not completed fit testing N95 with facility staff. All other items in the Control Module were answered yes. Infection Control module was addressed with administrator to satisfaction. Between 10:45 a.m. and 2:00 p.m., LPA reviewed staff schedule and found 3 individuals working at the facility without a California Criminal Record clearance. 4 other cleared individuals were not listed on the Personnel Roster but were listed on the staff schedule. LPA issued citation under Title 22, Division 6 Chapter 8 Article 06. Background Check 87355 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: (1) Obtain a California clearance or a criminal record exemption as required by the Department or (2) Request a transfer of a criminal record clearance as specified in Section 87355(c). LPA showed a demonstration of Guardian, the Personnel Roster Management System created by California Department of Social Services, to facility staff to help staff understand how to check for clearances and current associations. Guardian was rolled out in 2021.

Deficiency issued on LIC 809D. An immediate civil penalty was issued. LPA conducted exit interview with administrator and emailed a copy of today's report and appeal rights to the administrator.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Toan LuongTELEPHONE: (626) 419-1827
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2022
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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Document Has Been Signed on 02/15/2022 02:11 PM - It Cannot Be Edited

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: MARIPOSA AT ELLWOOD SHORES
FACILITY NUMBER: 425802106

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(1)
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: (1) Obtain a California clearance or a criminal record exemption as required by the Department or

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 in 3 counts which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/16/2022
Plan of Correction
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Administrator removed staff from the facility and schedule. Administrator will hold an in-service for directors and submit training log to LPA by 2/16/22
Type A
Section Cited
CCR
87355(e)(2)
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: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

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 in 4 counts which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/16/2022
Plan of Correction
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Administrator removed staff from the facility and schedule. Administrator will hold an in-service for directors and submit training log to LPA by 2/16/22

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Toan LuongTELEPHONE: (626) 419-1827
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2022
LIC809 (FAS) - (06/04)
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