425802106-8-9-2023-29-AS-KKOS-CUJVVQ-20230809164643

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425802106
Report Date: 08/09/2023
Date Signed: 08/09/2023 04:47:18 PM

Document Has Been Signed on 08/09/2023 04:47 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 SHORES		FACILITY NUMBER:	425802106
ADMINISTRATOR:	MARK CORTES		FACILITY TYPE:	740
ADDRESS:	190 VIAJERO DR		TELEPHONE:	(805) 265-4327
CITY:	GOLETA	STATE: CA	ZIP CODE:	93117
CAPACITY:	99	CENSUS: 61	DATE:	08/09/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Mark Cortes, Administrator		TIME COMPLETED:	05:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced required Annual Inspection at the above-named facility. LPA arrived at 11:30 AM and was greeted by Staff 1 (S1). Administrator Mark Cortes was present at the time of arrival. There were 41 residents in care in the Assisted Living unit with 1 medication technician, 2 caregivers on duty, and 1 activities coordinator on duty. In the “Compass Rose” Memory Care unit, there were 20 residents with 1 medication technician and two caregivers. The Compass Rose Lifestyle Director who currently oversees the activity programming for the Memory Care units of the facility was also on duty. LPA explained the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE) and is home to non-ambulatory residents with a dementia diagnosis. There are 5 residents currently on hospice. Entrance interview conducted: The physical environment was checked for cleanliness and condition. Walls, windows, ceilings, doors, floors and floor coverings were checked. The facility was seen to be in good repair inside and outside. Throughout the facility, there are approximately 12 fire extinguishers and 5 fire pull alarms. The pull fire alarms alert the local fire department when activated. Fire inspection was most recently conducted on 6/6/2023. There are approximately 81 dual carbon monoxide detectors and smoke alarms throughout the facility. The kitchen area was sufficiently stocked with two-day perishables and seven days of non-perishables. Snacks and beverages are readily available for Residents. LPA observed the dining areas are clean. LPA observed kitchen cabinets, refrigerator, stove, and counters are clean. Assisted Living Residents participate in activities such as special occasion celebrations, music entertainment, Boce ball, physical therapy, and excursions to local eateries and retail businesses. Memory Care residents participate in activities such as special occasion celebrations, music entertainment, and scenic drives. A "Cycling without Age" activity is available for residents in Assisted Living and Memory Care. Please continue to 809-C, Pg 2.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2023

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: MARIPOSA AT ELLWOOD SHORES	FACILITY NUMBER: 425802106
	VISIT DATE: 08/09/2023

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Medications and First Aid supplies/kits are kept in locked cabinets in the Assisted Living nurse’s station and in the Memory Care nurse’s station.
The facility has various sitting areas throughout the first and second floors including a library/reading area, faux fireplace, computer/business center for residents and staff, beauty salon, physical therapy center, and a laundry room.
The facility grounds are well maintained with walkways, sitting areas with covered tables and chairs, and raised garden areas. Throughout the interior area and outdoor area, the facility is conducive for socially distanced visitation.
Chemicals and cleaning supplies are kept in two locked closets with no access to residents in care.
The facility maintains a comfortable temperature. Hallways, bedroom doors, and walls are in good repair.
Emergency Disaster plan is posted and all agencies with telephone numbers are listed.

Due to time restraints, LPA will return at a later date to continue the inspection.

Copy of report issued at the time of the visit.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2023

LIC809 (FAS) - (06/04)

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