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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425802106
Report Date: 03/30/2022
Date Signed: 03/30/2022 02:58:21 PM


Document Has Been Signed on 03/30/2022 02:58 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:
03/30/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Denay RamirezTIME COMPLETED:
03:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Toan Luong conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control #29-AS-20210830163115). LPA Luong met with
Business Administrator Denay Ramirez. The purpose of the visit is to issue a citation for a deficiency observed during the complaint investigation.

During the complaint investigation of complaint #29-AS-20210830163115, Investigator Santana observed the following deficiencies:

R1’s Service Plan dated 07/24/2021, was not updated until 09/01/2021, even though a reassessment should have been completed after the fall incidents, the last fall being on 08/16/2021.

R1 had a fall on 08/07/2021 and 08/16/2021 sustaining injuries which required hospitalization. There is no record the Regional Office received any Unusual Incident Reports (UIRs) for the 08/07/2021 and 08/16/2021 incidents. The Director stated she must have mistakenly “shredded” the coversheets for the 8/7/2021 and 8/16/2021 UIRs and could provide no proof of submission .

In addition, the Facility Resident Services Director maintained that she faxed the 08/07/2021 incident report to the Regional Office on 08/11/2021, even though the Director was not working at the facility on 8/10/2021 or 8/11/2021, and a substitute nurse filled in for the Director on those dates.

LPA issued citation, conducted exit interview, and emailed appeal rights and report to Business Administrator.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Toan LuongTELEPHONE: (626) 419-1827
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2022
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 03/30/2022 02:58 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: 03/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
04/01/2022
Section Cited
CCR
87463(a)

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87463 Reappraisals (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate...
This requirement is not met as evidenced by:
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Licensee will submit plan how you will ensure Reappraisals are conducted in a timely manner when there is a change in resident condition. Submit to CCL by 4/1/22
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Based on records review and interviews, the licensee did not comply with the section cited above. R1’s Services Plan dated 07/24/2021 was not updated after R1 sustained multiple falls requiring hospitalization, which posed an immediate health and safety risk to residents in care.
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Deficiency Dismissed
Type A
04/01/2022
Section Cited
CCR87207

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87207 False Claims. No...employee of a licensee shall make or disseminate any false or misleading statement...This requirement is not met as evidenced by: Based on record review and interviews, the licensee did not comply with the section cited above.The Facility Resident Services Director stated she
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Licensee has agreed to do the following:
1. Schedule a training on conduct inimical and false claims. Training must be conducted by an approved vendor.
2. 2. Submit a letter to CCLD indicating the vendor's name, address, phone number, and date of the training.
Training must take place by
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faxed incident report to the Regional Office on 08/11/2021, however, the Investigator learned that a substitute nurse filled in for the Director at the facility on 08/10/2021 and 08/11/2021, which posed an immediate health and safety risk to residents in care.
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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.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Toan LuongTELEPHONE: (626) 419-1827
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 03/30/2022 02:58 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: 03/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
04/05/2022
Section Cited
CCR
87211(a)(1)(B)

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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports...(1)(B) Any serious injury...occurring while the resident is under facility supervision.
This requirement is not met as evidenced by: Based on records review, the
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Licensee will review 87211 Reporting Requirements regulation and submit a memo of understanding regarding submitting incident reports timely to appropriate parties. Submit to CCL by 4/5/22
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licensee did not comply with the section cited above. R1 had a fall on 08/07/2021 and 08/16/2021 sustaining injuries which required hospitalization, no incident reports were received for the incidents, which posed a potential health and safety risk to residents in care.
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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.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Toan LuongTELEPHONE: (626) 419-1827
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3