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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425802106
Report Date: 11/30/2022
Date Signed: 11/30/2022 06:35:58 PM


Document Has Been Signed on 11/30/2022 06:35 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:MARK CORTESFACILITY TYPE:
740
ADDRESS:190 VIAJERO DRTELEPHONE:
(805) 265-4327
CITY:GOLETASTATE: CAZIP CODE:
93117
CAPACITY:99CENSUS: 77DATE:
11/30/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Mark Cortes, AdministratorTIME COMPLETED:
06:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kristin Kontilis conducted a Case Management visit to address deficiencies noted during Complaint Control #29-AS-20221121125215 investigation visit conducted on 11/30/2022. LPA met with Administrator Mark Cortes and explained the purpose of the visit.
Interviews revealed the facility subcontracts with a home care agency to provide care and supervision staffing to residents in care and a nursing consultant agency. LPA reviewed Department of Social Services, Community Care Licensing Division, Licensing Information System (LIS), Facility Personnel Report summary and home care agency’s staff schedule.
Documents obtained and interviews conducted revealed eighteen (18) of the staff from the home care agency currently work or have worked in the facility from 7/22/2022 through 11/27/2022 and were not associated to the facility prior to providing staffing assistance.
Documents obtained and interviews conducted revealed three (3) consulting nurses (CN) have been present, currently work and/or have worked in the facility prior to being associated to the facility. CN1 was present and/or worked on 11/8/2022, 11/9/2022, and 11/10/2022; CN2 was present and/or worked on 11/21/2022 and 11/22/2022; CN3 was present and/or worked on 11/29/2022 and 11/30/2022.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Civil penalties assessed.

Exit interview conducted. Copy of report, Appeal Rights, and civil penalties issued via email.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2022
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 11/30/2022 06:35 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: 11/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/01/2022
Section Cited

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87355(e)(2) Criminal Record Clearance. (e) All individuals subject to a criminal record review...shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)
This requirement is not met as evidenced by:
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Based on record review and interview, the licensee did not comply with the section cited above as prior to being present and/or working in the facility, 18 home care agency staff, 3 nursing consultants, 1 corporate regional director were not associated to the facility which poses 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: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2022
LIC809 (FAS) - (06/04)
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