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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425802106
Report Date: 07/18/2023
Date Signed: 07/18/2023 02:58:06 PM


Document Has Been Signed on 07/18/2023 02:58 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: 45DATE:
07/18/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Mark Cortes, AdministratorTIME COMPLETED:
03:15 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-20230711113736 investigation visit conducted on 7/18/2023. LPA met with Mark Cortes and explained the purpose of the visit.

At approximately 12:15 pm, Staff 1 (S1) assisted LPA to the Resident Service Director’s office. Upon entering the Resident Service Director office, LPA observed the Resident Service Director’s office door fully open with approximately 9 or 10 residents’ binders visible from the facility hallway. LPA observed one binder was on top of the office desk fully open. At approximately 12:25 pm, Resident Services Director entered the Resident Services Director's office.
Resident Service Director stated she was in the Memory Care area of the facility at the time that LPA observed the office door open. Resident Service Director stated she is often out of her office and understands the door should be closed and locked when she is not in the office.


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

Exit interview conducted. Copy of report and Appeal Rights 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: 07/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2023
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 07/18/2023 02:58 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: 07/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/19/2023
Section Cited
CCR
87506(c)

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87506(c) Resident Records: All information and records obtained from or regarding residents shall be confidential.

This requirement is not met as evidenced by:
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Administrator agrees to conduct an in-service with facility staff to maintain compliance with HIPAA regulations and will keep the residents' records confidential.
Administrator will provide in-service training documents to LPA via email no later than 7/19/2023.
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Based on observation and interview, the licensee did not comply with the section cited above as Residents' records were exposed when the Resident Service Director office door was observed to be fully open 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: 07/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2023
LIC809 (FAS) - (06/04)
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