425802106-4-12-2023-29-AS-KBUY-CR7LQB-20230424085716

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 425802106
Report Date: 04/12/2023
Date Signed: 04/12/2023 02:11:27 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 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
03/22/2023 and conducted by Evaluator Brian Phillips

COMPLAINT CONTROL NUMBER: 29-AS-20230322155008

FACILITY NAME:	MARIPOSA AT ELLWOOD SHORES		FACILITY NUMBER:	425802106
ADMINISTRATOR:	MARK CORTES		FACILITY TYPE:	740
ADDRESS:	190 VIAJERO DR		TELEPHONE:	(805) 265-4327
CITY:	GOLETA	STATE: CA	ZIP CODE:	93117
CAPACITY:	99	CENSUS: 57	DATE:	04/12/2023
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Mark Cortes, Executive Director		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Facility does not have an adequate emergency disaster plan in place for residents requiring use of the elevator

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Brian Phillips conducted an unannounced subsequent complaint visit to issue final findings for the allegation above. LPA arrived at the facility at approximately 11:30am and announced the purpose of the visit. LPA met with Mark Cortes, Executive Director.
During the initial complaint visit, LPA conducted in-person interviews on 3/28/2023 from 11:45am through 2:15pm and obtained copies of documents pertaining to the investigation. LPA conducted additional interviews with responsible parties and witnesses on 4/11/2023 from 9:15am to 9:45am, and on 4/10/2023 from 11:00am through 11:30am.

On the allegation: Facility does not have an adequate emergency disaster plan in place for residents requiring use of the elevator. It was alleged the power went out at the facility at 4 AM on 3/22/23 and the facility elevator is not hooked up to the generator so there is no working elevator during a power outage. It was alleged staff told all the residents to stay in their room until the power came back on, and that there are many residents in wheelchairs and walkers that cannot go down the stairs in an emergency. Contd. 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Brian Phillips	TELEPHONE: (805) 956-1636
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20230322155008

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MARIPOSA AT ELLWOOD SHORES	FACILITY NUMBER: 425802106
	VISIT DATE: 04/12/2023

NARRATIVE

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Staff interviewed by the LPA stated that in an event of an emergency, the facility is equipped with an emergency generator that the appropriate safety member ensures has sufficient fuel and is always working properly. The backup generator ensures that power assisted devices for residents that require them will be immediately assisted in the event of a power outage (oxygen concentrators, motorized scooters, motorized beds for repositioning, and CPAP machines). If resident call buttons are inoperable during a power failure, staff will check on residents every 15 minutes until power is restored. Staff stated that if the elevators are not operational during a power outage, then residents will be assisted by "stair chairs" which are located next to each stairwell in the facility or by two person carry. Staff have been previously trained on the usage of stair chairs in 2023 and there is another subsequent scheduled stair chair training to take place for the staff within the next few months. Staff have documented training on the two person carry system in the facility disaster manual.

The emergency disaster plan for the facility includes evacuations of non-ambulatory residents, resident care during an emergency/disaster, elevator failure, power failure, disaster procedures, and 72-hour self-reliance. Non-ambulatory residents are identified on the resident roster. Methods of assisting non-ambulatory persons with evacuation if the elevators are not operational include removal by wheelchair, two person rescue carry, and the use of Stair Evacuation Chairs to remove non-ambulatory residents. The facility has documented Disaster Checklists for elevator failure and for power failure to organize appropriate procedures in the event of an emergency. At the time of a power failure in the facility, the elevator should automatically return to the first floor. If this does not occur, the elevator maintenance company will be immediately contacted for assistance. There are two evacuation routes out of the facility from the second floor, and evacuation routes/maps are posted throughout the facility. Residents who require assistive devices that require power will be immediately assisted if emergency power generators are not available. Assistive devices will be available for residents that require assistance with ambulation. During a power failure the resident will be assisted to use the Stair Chairs, or other assistive techniques as necessary. Staff safety monitors will ensure residents with ambulatory restrictions bring assistive devices (canes, walker, wheelchair, etc.) with them during an evacuation or relocation. These assistive devices will be labeled with the resident’s name prior to any disaster/emergency. Contd. on 9099-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Brian Phillips	TELEPHONE: (805) 956-1636
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2023

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20230322155008

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MARIPOSA AT ELLWOOD SHORES	FACILITY NUMBER: 425802106
	VISIT DATE: 04/12/2023

NARRATIVE

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In the event of a disaster/emergency including long term power failure, the facility has documented procedures to be self-reliant for at least 72 hours. Staff communicate with emergency services and licensing agencies on an ongoing basis to discuss evacuation/relocation. Appropriate staff safety supervisors coordinate ongoing provision of resident care, and residents are discouraged from going outside during the 72 hour self-reliance in the event of a major disaster/emergency.

Staff have a disaster/emergency training record documented in the facility disaster manual. Staff also have a documented disaster drill record occurring at least once every 6 months for each shift. The facility uses a process of “Tabletop Drills” to include residents in the simulated disaster drills. During “Tabletop Drills” the staff Disaster Leader and Safety Supervisors meet with residents in a group setting to discuss responsibilities and how to react to emergency scenarios.

LPA interviewed Residents in the facility about the allegation. Residents indicated everything was fine at the facility and did not have any issues. No resident indicated to the LPA that they had needed the use of the elevator while the power was out, and no resident indicated any issues with alternative forms of transportation from the second floor to ground level.

Based on the information obtained, there was insufficient evidence to prove the allegation. Therefore, it is deemed Unsubstantiated at this time.

Exit interview conducted. Copy of report sent via email and printed.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Brian Phillips	TELEPHONE: (805) 956-1636
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2023

LIC9099 (FAS) - (06/04)

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