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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425802106
Report Date: 06/13/2024
Date Signed: 06/13/2024 11:39:39 AM

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
10/20/2023 and conducted by Evaluator Kristin Kontilis
COMPLAINT CONTROL NUMBER: 29-AS-20231020165322
FACILITY NAME:MARIPOSA AT ELLWOOD SHORESFACILITY NUMBER:
425802106
ADMINISTRATOR:MARK CORTESFACILITY TYPE:
740
ADDRESS:190 VIAJERO DRTELEPHONE:
(805) 265-4327
CITY:GOLETASTATE: CAZIP CODE:
93117
CAPACITY:99CENSUS: DATE:
06/13/2024
UNANNOUNCEDTIME BEGAN:
09:12 AM
MET WITH:Sheryl McCaskill, Interim AdministratorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff did not respond to resident's request for assistance as necessary.
Staff did not report an incident involving resident to their Responsible Party as required.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kristin Kontilis conducted a subsequent complaint visit to the facility above to issue final findings. LPA met with Sheryl McCaskill, Interim Administrator and explained the purpose of the visit. During the investigation, LPA Kontilis conducted an initial visit on 10/25/2023 from 11:00 am to 4:15 pm. LPA conducted staff interviews and obtained documents.
On the allegation: Staff did not respond to resident's request for assistance as necessary:
It was alleged that Resident 1 (R1) fell and broke their hip on 10/4/2023. It was alleged R1 pushed their call button for an extended period of time and cried for help. However, R1 did not receive assistance until a visitor opened their door and called 9-1-1.
R1’s family member stated R1 typically goes to dinner between 4:45 pm and 5:00 pm. R1 stated on 10/4/2023, they were in their bathroom changing their clothes for dinner, and suddenly fell. R1 stated they pushed their call button, and it took the staff a “long time” to get there, estimating approximately

Please continue to 9099-C, Pg 2.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
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 4
Control Number 29-AS-20231020165322
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: 06/13/2024
NARRATIVE
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45 minutes. R1 stated they were banging on the door to let someone know they needed assistance. R1 stated their hand was getting numb from hitting the door and they had bruises on their hand, arm, and legs from trying to signal for help. R1 stated a visitor found them and summoned staff. R1 stated they have only pressed their pendant once or twice in the past. R1’s visitor signed into the facility at 5:39 pm, which was confirmed by visitor logs. Visitor went upstairs to R1’s room, where they heard R1 yelling for help. Visitor stated they went back downstairs to the front desk and asked for staff to open the door immediately. Staff told the visitor there was another emergency on the same floor. Visitor went back to the second floor and searched for another staff, who opened R1’s door and then left. Visitor stated R1 was in the bathroom, behind two closed doors, banging for help. Visitor left to find help and found a staff in the kitchen. The staff immediately called for help on the walkie talkie and went to R1’s room with the visitor. Staff called 9-1-1. Information from visitor and R1’s family member confirmed the visitor first called family at 5:58 pm, then 6:00 pm and 6:11 pm. The incident report submitted by the facility indicates R1 was discovered around 5:45 pm.
Former administrator indicated the facility has a 10-minute response time to their call buttons. LPA reviewed facility call button logs. LPA observed an entry for 10/4/2023 at 5:12:46 pm where R1 pressed their pendant. It states it took 35 minutes and 3 seconds for staff to respond, at 5:47:49 pm. For the time period of 10/3/2023 to 10/4/2023, LPA observed 3 calls that were between 20 and 40 minutes, and 3 calls that were over 40 minutes. LPA also observed one call for a resident was listed at 117 minutes 4 seconds.
An interview with a credible witness revealed they discussed call button times with the former administrator on 10/24/2023. Witness stated the staff have just been saying “Copy” but then do not respond to the call. Per witness, former administrator was going to change the policy to ensure staff responded promptly, or else another staff would be notified to respond. Based on the information obtained, the allegation is deemed Substantiated at this time.

On the allegation: Staff did not report an incident involving resident to their Responsible Party as required:
It was alleged that the facility refused to provide R1’s responsible party a copy of the incident report. R1’s family member stated family met with the former administrator on 10/24/2023 to discuss the incident with R1. Former administrator indicated they were not able to release the written incident report to them due to corporate policy. A credible witness also indicated they were not able to obtain call button logs due to ‘corporate policy.’

Please continue to 9099-C, Pg 3.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 29-AS-20231020165322
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: 06/13/2024
NARRATIVE
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LPA reviewed the incident report for R1’s fall on 10/4/2023. The incident report states R1’s responsible party was called and notified but does not indicate they were notified in writing as required per regulation. Based on the information obtained, the allegation is deemed Substantiated at this time. Technical Assistance is also provided to remind the Administrator of section 87468.2(a)(19) Personal Rights, which states residents have the right “To have prompt access to review all of their records and to purchase photocopies of their records. Photocopied records shall be provided within two (2) business days and at a cost that does not exceed the community standard for photocopies.”

The following deficiencies were observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in additional civil penalties.



Exit interview conducted. A copy of the report and appeal rights were issued at the time of the visit.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 29-AS-20231020165322
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: 06/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/14/2024
Section Cited
HSC
1569.312(a)
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Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision as defined in Section 1569.2.

This requirement is not met as evidenced by:
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Administrator agrees to provide staff training on call button response expectations. Administrator will provide proof training is scheduled by 6/14/2024, and administrator will provide proof of training by 6/21/2024.
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Based on interviews and records review, the licensee did not comply with the section cited above when they failed to respond to R1’s call button for assistance, which posed an immediate health and safety risk to residents in care.
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Type B
06/17/2024
Section Cited
CCR
87211(a)(1)
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87211(a)(1) Reporting requirements. A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This requirement was not met as evidenced by:
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Administrator agrees to provide R1’s responsible party a copy of the incident report. Administrator stated a copy of the report will be sent via USPS Certified Mail with Return Receipt.
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Based on interviews and record review, the licensee did not comply with the section cited above when they did not notify R1’s RP of a fall in writing, which posed a potential health, safety and personal rights 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: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4