425802106-8-4-2022-29-AS-KBUY-CH5UM4-20220809154140

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 425802106
Report Date: 08/04/2022
Date Signed: 08/04/2022 06:47:47 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/07/2022 and conducted by Evaluator Jeannette Olson

COMPLAINT CONTROL NUMBER: 29-AS-20220107092824

FACILITY NAME:	MARIPOSA AT ELLWOOD SHORES		FACILITY NUMBER:	425802106
ADMINISTRATOR:	PETER JOHN BONILLA		FACILITY TYPE:	740
ADDRESS:	190 VIAJERO DR		TELEPHONE:	(805) 265-4327
CITY:	GOLETA	STATE: CA	ZIP CODE:	93117
CAPACITY:	99	CENSUS: 80	DATE:	08/04/2022
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Peter Bonilla, Administrator		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Facility did not repair resident's door

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPA) Olson and Kontilis conducted an unannounced complaint visit to issue final findings. LPA Olson met with Peter Bonilla, Administrator and Mark Cortes, Interim Administrator and explained the purpose of the visit. LPA Diaz conducted the initial 10-day complaint visit on 1/12/22. LPA Luong conducted a follow up investigation visit on 2/15/22 and interviewed Administer. On 7/15/22 LPA Olson called the Administrator for an additional interview and requested R1’s door service ticket. Administrator was unable to find service ticket. LPA Olson interviewed staff on 7/27/22 and 7/29/22. LPA interviewed R1’s family on 7/27/22.

On the allegation: Facility did not repair resident's door. Reporting Party (RP) stated that Resident 1 (R1) had a door that didn’t work and had to request the door be opened with a special key. On 1/5/22, an email from R1’s family revealed the electronic entry to R1’s door was not functioning properly and noticed two weeks ago when they were at the facility, when they swiped the key, it would flash green for one second and then it would immediately turn red and would take a few tries to get the door open. Continued on 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 5

Control Number 29-AS-20220107092824

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 08/04/2022

NARRATIVE

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R1 would have to ask the staff to open the door. R1’s family member did not report it to staff or the administrator initially because they figured the staff would. Administrator interview revealed that R1 is declining cognitively, as evidenced by his behaviors. Administrator stated in order for the facility to handle maintenance issues, the resident would need to report the issue by calling the front desk. Then a service request would be made, then the door would be fixed. Staff interviews revealed that R1 had multiple door issues and there were at least two instances that R1’s door needed new batteries and one where it needed a new part. Based on interviews and emails provided, multiple maintenance issues occurred with R1’s door, over the span of about two weeks. Therefore this allegation is deemed substantiated at this time.

Exit interview conducted, 9099-D, appeal rights, and report emailed to Administrator.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 29-AS-20220107092824

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/04/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/04/2022 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303(a) Maintenance and Operation: 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 was not as evidenced by:	1 2 3 4 5 6 7	Administrator stated that the door was fixed in January 2022. The POC was cleared during the visit.
	8 9 10 11 12 13 14	Based on interviews, the licensee failed to ensure that R1’s door was functioning, which posed a potential health and safety risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/07/2022 and conducted by Evaluator Jeannette Olson

COMPLAINT CONTROL NUMBER: 29-AS-20220107092824

FACILITY NAME:	MARIPOSA AT ELLWOOD SHORES		FACILITY NUMBER:	425802106
ADMINISTRATOR:	PETER JOHN BONILLA		FACILITY TYPE:	740
ADDRESS:	190 VIAJERO DR		TELEPHONE:	(805) 265-4327
CITY:	GOLETA	STATE: CA	ZIP CODE:	93117
CAPACITY:	99	CENSUS: 80	DATE:	08/04/2022
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Peter Bonilla, Administrator		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Facility doesn't serve meals timely to resident with elected service.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPA) Olson and Kontilis conducted an unannounced complaint visit to issue final findings. LPA's met with Administrator Peter Bonilla and Mark Cortes, Interim Administrator and explained the purpose of the visit. LPA Diaz conducted the initial 10-day complaint visit on 1/12/22. LPA Luong conducted a follow up investigation visit on 2/15/22 and interviewed Administer. On 7/15/22 LPA Olson called the Administrator for an additional interview and requested R1’s door service ticket. Administrator was unable to find service ticket. LPA Olson interviewed staff on 7/27/22 and 7/29/22. LPA interviewed R1’s family on 7/27/22.

On the allegation: Facility doesn't serve meals timely to resident with elected service. Reporting Party (RP) stated R1 would have to wait a long time (30-60 minutes) for breakfast due to residents needing to self-serve their own breakfast, instead of it being served directly to residents. Other meals, such as dinner, are directly served to residents. An email sent to the facility on 1/5/22 from R1’s family states
Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 29-AS-20220107092824

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 08/04/2022

NARRATIVE

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R1 dislikes going down to the dining room due to not receiving assistance and has to go to the kitchen entrance to get someone’s attention. Interviews with staff and R1’s family revealed that R1 would request breakfast outside of the scheduled time. R1 was given cereal and other snacks to tide R1 over until breakfast hours. Administrator interview revealed that R1 recently started receiving tray service and was not used to the process yet. Administrator also stated that if the kitchen was slow R1 would be upset if staff wouldn’t respond immediately to R1’s call. To help R1 adjust to tray service, the facility switched the order of tray deliveries so R1’s floor was served first. The meals were still provided/served timely according to regulations, and the facility changed their tray service schedule to try to accommodate R1. Based on interviews, this allegation is deemed unsubstantiated at this time.

Exit interview conducted, report emailed to Administrator.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022

LIC9099 (FAS) - (06/04)

Page: 5 of 5