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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425802106
Report Date: 06/17/2024
Date Signed: 06/20/2024 09:42:55 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
11/21/2022 and conducted by Evaluator Kristin Kontilis
COMPLAINT CONTROL NUMBER: 29-AS-20221121125215
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:
06/17/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Sheryl McCaskill, Interim AdministratorTIME COMPLETED:
06:30 PM
ALLEGATION(S):
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Facility staff did not meet the needs of resident(s) in care.
Facility has insufficient staffing.
Facility staff did not respond to residents’ call for help.
Facility staff are not adequately trained.
Facility staff did not treat resident with dignity and respect.
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 11/30/2023 from 12:35 pm to 6:10 pm, toured the facility, conducted interviews, and obtained documents. LPA also interviewed staff and residents on 6/13/2024 and 6/17/2024 and obtained additional documents.
On the allegation: Facility has insufficient staffing. It was alleged the facility had insufficient staffing. LPA observed staffing schedules for July 2022 through November 2022. LPA also observed additional agency staff the facility contracted from July 2022 through November 2022, that coincided with days when less facility staff were present. LPA observed a large number of agency staff used in October and November 2022. Residents interviewed indicated sometimes the staff are spread thin, but they work hard to provide care. Residents noted during the COVID-19 outbreak, staff routinely checked on them in their rooms.
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: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2024
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 9
Control Number 29-AS-20221121125215
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: 06/17/2024
NARRATIVE
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Interviews revealed in 2022, the facility did not have a chef for approximately 6 weeks, and management helped with cooking. Residents indicated there were multiple current vacancies at the facility, including administrator (which is being filled by interim corporate managers), activities director, facilities maintenance director, and personal services director. Staff interviewed stated caregivers were serving food in the kitchen without having a food handling certificate. Staff did not believe there were enough staff, especially if staff call out.
Multiple residents interviewed stated the meal service is very slow due to a lack of staffing. LPA reviewed staffing scheduled for May and June 2024. LPA observed some days have 3 dining staff total, while other days have 7 dining staff total. LPA observed on 5/17/2024, 5/18/2024, 5/25/2024, 2 staff at breakfast and lunch, but only 1 staff for dinner. On 6/13/2024, LPA observed 5 staff at breakfast, 4 staff at lunch, and 2 staff at dinner. Interim administrator stated they have 1 server and caregiver assigned for breakfast and at lunch. Residents indicated breakfast took 1.5 hours recently, and noted coffee and tea are no longer on the counter so servers have to bring the beverages, adding to the long service times. Some residents stated they don’t eat breakfast anymore because the wait was so long. One resident interviewed indicated they complained about the long service time to a server, and the server stated they were only one person. Multiple residents interviewed indicated they believe the staff are overworked and are not getting the help they need, as evidenced by the long wait times. Responsible party 3 (RP3) stated if the resident’s food is not ready when they take medication, they are unable to take their medication on time. Based on the information obtained the allegation is deemed Substantiated at this time.

On the allegation: Facility staff did not respond to residents’ call for help. It was alleged staff do not respond timely to residents’ call buttons. Administrator at the time indicated the maximum response time should be 10-mintes. LPA reviewed call button logs for October 2022. LPA reviewed 295 pages of call log summaries, with hundreds of entries. LPA observed many calls that were under the 10-minute target response time. However, LPA observed 19 calls that were 30-39 minutes; 12 calls that were 40-49 minutes; 3 calls 50-59 minutes; 4 calls 60-79 minutes; 3 calls 80-99 minutes; 3 calls 100-149 minutes; one call that was 151 minutes; one call was 1,387 minutes; and one call was 2,838 minutes. LPA reviewed an on-site in-service training sheet dated 11/10/2022 conducted my administrator at the time. Topics discussed include “pendant response times.” Another training dated 10/19/2022 reminded staff the pendant logs can be printed. It states staff cannot have calls unanswered for more than 10 minutes and notes the average response time is 7 minutes. Based on the information obtained, the allegation is deemed Substantiated at this time.
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: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 9
Control Number 29-AS-20221121125215
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: 06/17/2024
NARRATIVE
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On the allegation: Facility staff are not adequately trained. It was alleged that due to a high staff turnover, staff were not properly trained. LPA reviewed training transcripts from 2022. Care staff training requirements include 40 hours training for new staff and 20 hours annual training for existing staff. LPA observed staff to have 6 hours, 5.25 hours, 4.75 hours, 25.5 hours, and 16.50 hours. Based on the information obtained, the allegation is deemed Substantiated at this time.

On the allegation: Facility staff did not treat resident with dignity and respect. It was alleged staff were not respectful to residents. RP2 stated on 11/9/2022 they emailed a staff that R2 gets agitated when they feel the staff are disrespectful or aggressive toward them. RP2 stated some of the staff were “not kind.” Responsible Party 1 (RP1) stated they observed the business office manager speak inappropriately to a resident. It was alleged on 11/4/2022, that R2 was agitated after an interaction with staff. R2 told the staff they did not get breakfast, and the staff took the box for breakfast out of the trash and threw it at R2, stating R2 did eat breakfast but they are not remembering. LPA reviewed an on-site in-service training sheet dated 11/10/2022 conducted my 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 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. A citation for this was already issued on complaint 29-AS-20221215114140 on 6/13/2024 so a duplicate citation will not be issued.

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: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 9
Control Number 29-AS-20221121125215
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: 06/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/24/2024
Section Cited
CCR
87411(a)
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87411(a) Personnel Requirements. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. Additional staff shall be employed as necessary to perform…cooking…
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Administrator agrees to submit a plan to ensure sufficient dining staff and decrease resident wait times for food. Administrator will submit by 6/24/2024.
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This requirement was not met as evidenced by:
Based on interviews, the licensee did not comply with the section cited when they did not employ sufficient dining staff, which posted a potential health and safety risk to residents in care.
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Type B
06/24/2024
Section Cited
CCR
87303(i)
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87303(i) Maintenance and Operation. Facilities shall have signal systems which shall meet the following criteria…

This requirement was not met as evidenced by:
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Administrator agrees to provide training to all staff of call button response time expectations. Administrator will submit by 6/24/2024.
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Based on records review, the licensee did not comply with the section cited above when staff did not answer calls timely, 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: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 9
Control Number 29-AS-20221121125215
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: 06/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/24/2024
Section Cited
CCR
87411(c)
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87411(c) Personnel Requirements. All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625…
This requirement was not met as evidenced by:
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Administrator agrees to provide a plan to ensure all staff receive adequate training going forward. Administrator will submit plan by 6/24/2024.
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Based on record reviews, the licensee did not comply with the section cited above when staff did not have adequate training in 2022, 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: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 9
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
11/21/2022 and conducted by Evaluator Kristin Kontilis
COMPLAINT CONTROL NUMBER: 29-AS-20221121125215

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:
06/17/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Sheryl McCaskill, Interim AdministratorTIME COMPLETED:
06:30 PM
ALLEGATION(S):
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Facility staff did not meet the needs of resident(s) in care.
Facility staff mismanaged resident’s medication.
Facility staff mishandled residents.
Facility did not report incidents.
Facility is in disrepair.
Facility staff did not follow COVID-19 guidelines.
Facility is unkempt.
Facility staff did not communicate with resident's responsible parties.
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 11/30/2023 from 12:35 pm to 6:10 pm, toured the facility, conducted interviews, and obtained documents. LPA also interviewed staff and residents on 6/13/2024 and 6/17/2024 and obtained additional documents.
On the allegation: Facility staff did not meet the needs of resident(s) in care. It was alleged staff did not provide timely toileting to Resident 1 (R1). Responsible Party 1 (RP1) stated on 9/6/2022, they found R1 lying on a urine-soaked pad, with their shirt soaked in urine and mattress wet. R1 indicated they pushed their pendant for help, but no one came. RP1 pushed the pendant again, but no staff came to assist until RP1 called the front desk from their cell phone. Per RP1, when staff arrived, they stated they did not
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: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 9
Control Number 29-AS-20221121125215
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: 06/17/2024
NARRATIVE
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respond sooner because they were short-staffed and were helping deliver meals to residents’ rooms. RP1 stated again on 10/23/2022, they found R1 on a urine-soaked pad, with their shirt wet. R1 stated no staff came to check on them all morning. RP1 pushed R1’s call button and staff provided care to R1. LPA reviewed call button logs for 10/23/2022 and observed quick response times to R1. Staff interviewed stated caregivers were on top of things, and they attend to soiled residents right away. Staff stated residents are checked every two hours if they need restroom assistance or incontinence care, or if they need repositioning. Staff all stated they worked to ensure residents are not soiled for an extended period of time. Staff stated some residents are combative when trying to be changed, but staff do their best and may provide residents PRNs for agitation.
Resident 2 (R2) received showers twice a week. Responsible Party 2 (RP2) stated on 10/31/2022, R2 missed their scheduled shower due to a medical appointment, but RP2 asked staff to make sure R2 got their shower. On 11/4/2022, R2 had not had a shower still, and staff stated R2 refused multiple showers. On 11/6/2022 R1 received a shower, 9 days after their last shower. Facility shower logs were unavailable for review. Staff stated they try to meet residents’ care needs but some residents are combative to care. Residents interviewed stated the staff are busy, and sometimes they don’t show up to provide the residents their showers on time/as scheduled. However, Residents interviewed indicated they believe overall staff are meeting residents’ needs. However, some noted they had difficulty communicating with the staff because they do not speak English, but they try to communicate through gestures. Technical assistance is provided to remind the licensee of their responsibility to have competent staff that can communicate appropriately with residents. Although the allegation may have occurred, there was insufficient evidence to prove it; therefore, the allegation is deemed Unsubstantiated at this time.
On the allegation: Facility staff mismanaged resident’s medication. It was alleged the facility mismanaged a resident’s medication. A responsible party (RP3) stated in June 2022, Resident 3 (R3) received the wrong medication for three days. RP3 also stated on 11/26/2022, during a COVID-19 outbreak, staff dropped off R3 and R4’s medication cups in their shared room, but did not ensure the residents took the medication. RP3 was concerned the medication cups could get mixed up and did not feel the facility was handling the medication properly. LPA reviewed incident reports submitted by the facility in 2022, and noted no medication issues were submitted. LPA reviewed R3’s file and did not observe medication issues in June 2022. However, LPA observed medication issues in July and August 2023. These were cited on complaint 29-AS-20230711113736. There was insufficient evidence to prove the allegation occurred in June 2022. Therefore, the allegation is deemed Unsubstantiated at this time.
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: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 9
Control Number 29-AS-20221121125215
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: 06/17/2024
NARRATIVE
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On the allegation: Facility staff mishandled residents. It was alleged that due to improper training, staff handled residents roughly. 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.” Some residents interviewed indicated they had never had an issue with handling them roughly. One resident stated they were aware of a resident who mishandled another resident but did not have an issue with staff. Staff interviewed indicated they were unaware of any staff mishandling or roughly handling residents. Although the allegation may have occurred, there was insufficient evidence to prove it. Based on the information obtained, the allegation is deemed Unsubstantiated at this time.
On the allegation: Facility is in disrepair. It was alleged the facility was in disrepair. Responsible Party 1 (RP1) stated they asked staff to repair R1’s toilet paper holder, and later asked the marketing director. Both staff and marketing director indicated they would put in a work order. RP1 stated despite multiple follow-ups, it took 5 weeks to get the repair complete. LPA observed the work order report for 7/15/2022 to 12/1/2022, and 168 work order requests. LPA observed the broken toilet paper holder reported twice with “medium” priority given. During the facility’s annual inspections on 8/4/2022, 8/9/2023, 9/8/2023, and 9/13/2023, LPA did not observe the facility to be is disrepair. LPA also did not observe any physical plant issues on 6/13/2024 or 6/17/2024. Based on the information obtained, the allegation is Unsubstantiated at this time. Technical assistance is provided to remind the facility to address any necessary repairs timely and appropriately.
On the allegation: Facility staff did not follow COVID-19 guidelines. Multiple responsible parties confirmed on 11/8/2022, the front lobby of the facility, adjacent to the dining room, was used as a public polling place for an election. It was alleged that as a result of the public in the building, the facility experienced a COVID-19 outbreak, with 9 cases by 11/14/2022, 25 cases by 11/17/2022, and 38 cases by 11/19/2022. Responsible parties feel that that it was dangerous and negligent of the facility to allow the public into the facility, near the resident’s dining room. CCL reviewed records and verified the facility reported the COVID-19 outbreak to CCL and local public health. The origin of the COVID-19 cannot be conclusively proven, and no guidance at the time of the complaint formally prohibited the facility from acting as a polling site. However, Technical Assistance is provided to the facility as a reminder of their responsibility to use good judgment to ensure resident safety and follow applicable public health guidelines. Based on the information obtained, the allegation is Unsubstantiated at this time.
Please continue to 9099-C, Pg 4
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2024
LIC9099 (FAS) - (06/04)
Page: 8 of 9
Control Number 29-AS-20221121125215
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: 06/17/2024
NARRATIVE
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On the allegation: Facility is unkempt. It was alleged resident’s rooms were not being cleaned. It was alleged a resident’s room did not get cleaned for 11 days. During the facility’s annual inspections on 8/4/2022, 8/9/2023, 9/8/2023, and 9/13/2023, LPA did not observe the facility to be unkempt or dirty. LPA also did not observe any physical plant issues on 6/13/2024 or 6/17/2024. Based on the information obtained, the allegation is Unsubstantiated at this time.
On the allegations: Facility staff did not communicate with resident's responsible parties, and Facility did not report incidents. It was alleged an incident where a resident sustained injury was not reported to the responsible party. Responsible Party 1 (RP1) stated on 11/16/2022, Resident 1 (R1) sustained an injury in their bathroom that resulted in substantial bleeding; however, RP1 was not notified. RP1 arrived and observed R1’s injury, pressed R1’s call button, and staff bandaged R1’s bleeding. RP1 noted R1 needed assistance in the bathroom, so staff should have been with R1 when it happened. RP1 stated on a subsequent interview, RP1 arrived at the facility on 11/6/2022 and observed R1 had a bandage on their arm. R1 got their arm stuck on a grab bar while toileting with staff, and R1 stated they bled a lot and a bandage was applied. RP1 asked the facility’s nurse for more information and why they were not informed, but the nurse was not aware of the incident. RP1 stated on 11/8/2022 a nurse visited R1, told R1 they had a vaginal infection and attempted to do a pelvic exam. RP1 was unaware of R1’s symptoms or the medical attention R1 was receiving. RP1 confirmed with R1’s doctor the facility faxed them about the symptoms. On 11/9/2022, RP1 stated they emailed the facility nurse about the lack of communication. LPA did observe incident reports submitted for these dates, but the incidents did not meet reporting requirements for CCL. LPA did not find sufficient evidence to corroborate the allegations although RP1 kept detailed notes of the issues. There was insufficient evidence to conclusively prove the allegation happened, therefore the allegation is deemed Unsubstantiated at this time. However, LPA reminded administrator of the requirement and importance of reporting incidents to both CCL and responsible parties, and keeping responsible parties informed.

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: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2024
LIC9099 (FAS) - (06/04)
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