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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425802106
Report Date: 12/20/2022
Date Signed: 12/20/2022 06:09:04 PM


Document Has Been Signed on 12/20/2022 06:09 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: 68DATE:
12/20/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Mark Cortes, AdministratorTIME COMPLETED:
04:00 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-20221215114140 investigation visit conducted on 12/20/2022. LPA met with Mark Cortes, Administrator and explained the purpose of the visit.

LPA conducted a physical tour of the facility. At approximately 1:38 pm, LPA entered the kitchen service area of the facility and observed Staff 1 (S1), Staff 2 (S2), Staff 3 (S3), and Staff 4 (S4) were not properly wearing face coverings. S1’s face covering was under the chin. S2’s face covering was under the chin. S3’s face covering was under the chin. S4’s face covering was under the chin. S1, S2, S3, and S4 were not eating or consuming a beverage. at the time of LPA's observation. LPA requested each staff member to properly cover their face with a proper face covering. LPA reminded staff members that a face covering is to be worn in the facility at all times.
At approximately 3:10 pm, LPA observed S1 in the hallway of the facility wearing a face covering below the nose. LPA again reminded S1 that the face covering must be worn over the nose and mouth at all times while in the facility. S1 stated the mask was too big. LPA recommended requesting a new mask that fits better.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D):

Exit interview conducted. Copy of report and Appeal Rights issued via email.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2022
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 12/20/2022 06:09 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: 12/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/22/2022
Section Cited

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87468.1(a)(2) Personal Rights of Residents in All Facilities: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement is not met as evidenced by:
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Administrator agrees notify all staff to wear masks at all times in the facility. Administrator agrees to conduct an infectious control training, review and train staff on all recent PIN’s released for 2022, ncluding mask-wearing mandates, and provide copy of training and staff signatures to CCL by 12/22/2022.
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Based on LPA observation, Licensee failed to ensure all staff wore face coverings properly at all times while in the facilities. Staff 1, Staff 2, Staff, 3, Staff 4 were not wearing a mask at the time LPA conducted a tour of the facility which poses an immediate health, safety and personal rights risk to residents in care.
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List of attendees with signatures to include first and last name of each attendee shall be provided to LPA via email.

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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: 12/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2022
LIC809 (FAS) - (06/04)
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