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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425802106
Report Date: 06/13/2024
Date Signed: 06/14/2024 07:52:41 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
12/15/2022 and conducted by Evaluator Kristin Kontilis
COMPLAINT CONTROL NUMBER: 29-AS-20221215114140
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: 69DATE:
06/13/2024
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Sheryl McCaskill, Interim AdministratorTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Staff speak inappropriately to residents in care.
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 12/12/2023 from 1:05 pm to 4:00 pm, and toured the facility and obtained documents. LPA also interviewed staff and residents on 6/13/2024 and obtained additional documents.

On the allegation: Staff speak inappropriately to residents in care. It was alleged that a staff spoke inappropriately to a resident. Responsible Party 1 (RP1) stated they observed the business office manager speak inappropriately to a resident. Responsible Party 2 (RP2) stated on 11/9/2022 they emailed the facility nurse that R2 gets agitated when they feel the staff are disrespectful or aggressive toward them. RP2 stated some of the staff were “not kind.” RP2 stated on 11/4/2022, R2 told the staff they did not get breakfast and

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 6
Control Number 29-AS-20221215114140
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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the staff took the box for breakfast out of the trash, threw it at R2, and stated R2 did eat breakfast but they are not remembering. LPA reviewed an on-site in-service training sheet dated 11/10/2022 conducted by administrator at the time. Topics discussed include “sensitivity training.” In the training notes, administrator discussed standards/expectations including “customer service,” and “exercise patience and slow down with resident interactions so you are better understood and so are they.” Administrator also notes “communication between staff should always be respectful and professional.” Another training dated 10/19/2022 states to be respectful and be kind. Residents interviewed indicated they had heard staff speak inappropriately to others. One resident interviewed stated a while ago a staff member was “a little huffy” responding to residents when they complained about slow meal service. Based on the information obtained, the allegation is deemed Substantiated at this time.

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: 2 of 6
Control Number 29-AS-20221215114140
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 B
06/20/2024
Section Cited
CCR
878468.1(a)(1)
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87468.1(a)(1) Personal Rights. Residents…have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons.
This requirement was not met as evidenced by:
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Administrator agrees to conduct personal rights training with all staff and provide proof of training by 6/20/2024.
Administrator agrees to submit proof of training via email including description of training, first and last name(s) of trainer(s) and trainees. Trainee signatures required.
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Based on interviews and record review, the licensee did not comply with the section cited above when staff spoke inappropriately to residents, which posed a potential 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: 3 of 6
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
12/15/2022 and conducted by Evaluator Kristin Kontilis
COMPLAINT CONTROL NUMBER: 29-AS-20221215114140

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: 69DATE:
06/13/2024
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Sheryl McCaskillTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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9
Staff did not seek timely medical attention for resident.
Staff do not serve nutritious meals for residents.
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 12/12/2023 from 1:05 pm to 4:00 pm, toured the facility, and obtained documents. LPA also interviewed staff and residents on 6/13/2024 and obtained additional documents.

On the allegation: Staff did not seek timely medical attention for resident. It was alleged that on 12/7/2022, Resident 1 (R1) passed out and was taken to the hospital. R1 was diagnosed with a Urinary Tract Infection (UTI). It was alleged that R1 was given a UTI test on 11/23/2022, which was positive on 11/25/2022, but was not provided treatment. The staff allegedly stated they not aware of the results.

Please continue to 9099-C, Pg 2.
Unsubstantiated
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: 4 of 6
Control Number 29-AS-20221215114140
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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On R1’s physician’s report dated 8/18/2022, it indicates R1 had a history of a kidney transplant and diabetes. The report is incomplete, with no marks about R1’s ability to complete Activities of Daily Living, including bathing self, dress/groom self, feed self, care for own toileting needs, and able to manage own cash resources. R1’s service plan dated 9/21/2022 states R1 may require stand-by assistance for ambulation, needs assistance with bathing twice a week, and needs assistance with application and removal of support stockings. There is no indication R1 needed assistance with toileting. R1’s updated assessment dated 10/20/2022 indicates they are alert and oriented, had no neurocognitive issues, and do not require additional status checks. R1 also handled some of their own medications, including insulin.

LPA reviewed incident reports for the facility for November and December 2022. LPA observed an incident report notifying CCL that R1 had COVID-19, but did not observe any other incident reports. LPA reviewed documentation from R1’s facility. The facility notified R1’s Primary Care Physician (PCP) of a fall on 11/1/2022 where the resident had no injuries, nor complaints of pain or discomfort, so they were not sent to the hospital. On 11/4/2022, R1 slid off their bed but stated they did not hit their head. On 11/7/2022, R1 had a fall and refused to go to the hospital. On 11/3/2022, 11/10/2022 and 11/16/2022, R1 was seen by home health where they provided bladder irrigation. The facility notified R1’s Primary Care Physician (PCP) that R1 tested positive for COVID-19 on 11/17/2022. R1 isolated in their apartment at the facility for 10 days. Charting notes for R1 indicate on 11/7/2022 on the PM shift R1 was weak, sleepy, with body aches, cough and runny nose. R1 went to the hospital to receive an IV infusion and returned. On 11/19/2022 R1 stated they “feel okay.” On 11/22/2022 R1 did not have any complaint of pain or discomfort. The other entries between 11/17/2022 and 11/26/2022 indicate R1’s temperature, heart rate, and oxygen saturation.

Charting notes for R1 indicate on 11/28/2022 during the PM shift, a visitor observed R1 to be more confused than normal. Staff checked on R1 and found them shaky with swollen feet and feeling nausea; 911 was called and paramedics found R1’s blood sugar to be high. Paramedics instructed R1 to take their insulin, which they forgot to do at lunchtime. R1 and paramedics agreed not to send R1 to the hospital, and R1 felt better after taking insulin. R1 was checked on multiple times during the shift. The overnight shift reported R1 stated they were doing better. On the morning of 11/29/2022, R1 woke up late and staff reminded R1 to take their medications and food. In the evening, R1 was wheeling self around the room putting clothes away.

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: 5 of 6
Control Number 29-AS-20221215114140
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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Staff asked R1 why they hadn’t touched their meals that were at their table. R1 stated they did not want the food. Staff offered for the cook to make a sandwich or hot dog, but R1 stated they would make food themselves. R1 was recovering from COVID-19, but staff noted R1 had a stuffy nose but stated they always had sinus issues due to allergies and were in good spirits. Later, R1 complained of a stomach ache and asked for pepto bismol, which they took and felt better. On 11/30/2022, R1 was found on the floor and taken to the ER. The facility also notified PCP of the fall. There were no documents in R1’s file indicating they had a urinary tract infection (UTI) or symptoms of a UTI. There was also no documentation that R1 was seen by a medical professional between 11/23/2022 and 11/25/2022. Based on the information obtained, the allegation is deemed Unsubstantiated at this time.
On the allegation: Staff do not serve nutritious meals for residents. It was alleged that the facility’s chef had quit and non-nutritious food was served. Two residents’ responsible parties both indicated the facility food was “not good” and “non-nutritious.” The Administrator at the time stepped in and assisted with cooking and serving meals. During the facility’s annual inspections on 8/4/2022 and 8/9/2023, the kitchen was inspected. LPA did not observe any spoiled or expired food during the inspections. Responsible Party 2 (RP2) stated Resident 2 (R2) was excited for hot dogs which were available on the “all day menu,” but R2 was told their responsible party did not want them eating hot dogs and was told they were out of hot dogs. Menu for 2022 was unavailable to review; however LPA reviewed menus from early 2023, which appear balanced. Residents interviewed stated the food was non-nutritious and the meals were “imbalanced.” Resident stated macaroni and rice were served together at a meal, so the meal was all starches and no vegetables. Residents stated they would agree there are some “nutrition drawbacks or inadequacies.” For example, the menu will say “ham slice” for dinner but the ham is very processed and is more like bologna. Resident noted many of the foods served are high in sodium, but the vegetables are getting better and salads are always available. Residents stated the meals were not great, and the food service is slow. Resident stated meatloaf was the meal today, but it was just ground meat and was not meatloaf. There was insufficient evidence to prove that the food did not meet Title 22 requirements, therefore the allegation is deemed Unsubstantiated. However, technical assistance is provided to notify the administrator that many residents interviewed were dissatisfied with the food, and communicated meals may be imbalanced or not as nutritious as they could be. In addition, some noted meat was tough or not cooked appropriately. Facility is advised to reconsider their menu and food offerings, and ensure kitchen staff have sufficient training to adequately serve the large number of residents in this facility.

Exit interview conducted. Copy of report 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: 6 of 6