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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801596
Report Date: 10/09/2024
Date Signed: 10/09/2024 08:15:16 PM


Document Has Been Signed on 10/09/2024 08:15 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 VALLEY, INC.FACILITY NUMBER:
565801596
ADMINISTRATOR:KARINA RAMIREZ VAZQUEZFACILITY TYPE:
740
ADDRESS:8217 TIARA ST.TELEPHONE:
(805) 659-4603
CITY:VENTURASTATE: CAZIP CODE:
93004
CAPACITY:6CENSUS: 6DATE:
10/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:06 PM
MET WITH:Karina Ramirez Vazquez, AdministratorTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced required Annual Inspection at the above-named facility. LPA were greeted by S1. Administrator Karina Ramirez Vazquez arrived at approximately 12:39 pm. LPA explained the purpose of the visit.
At the time of arrival, there were six residents in care and one caregiver on duty. The facility is a Residential Care Facility for the Elderly (RCFE) The facility accepts residents with a dementia diagnosis; has a hospice care waiver for two (2) residents; and a fire clearance for six (6) non-ambulatory residents. Currently there are no residents on hospice residing in the facility.
Entrance interview conducted.
The facility is a one-story facility located in a residential area. A tour of the physical environment was assessed to ensure there are no safety hazards. LPA observed the required posting of the complaint poster and Resident’s Rights. LPA inspected the one-story facility for fire safety, personal accommodations, and food service.
Entrance into the facility is into the foyer area and leads into a common area. The floor plan includes a dining area, kitchen, TV room, two private bedrooms, one shared bedroom with a private bath, one shared bedroom with no bathroom, and a bathroom at the end of the hallway accessible to all residents in care.
The physical environment was checked for cleanliness and condition. Walls, windows, ceilings, doors, floors and floor coverings were checked. The facility was seen to be in good repair inside and outside. LPA observed the fire inspection was last conducted on 9/16/2024. LPA observed 10 dual carbon monoxide/smoke alarms were in good working order.
The bathrooms have secure grab bars and no-skid flooring. Between 12:30 pm and 12:37 pm, LPA measured the water temperature of the hallway bathroom at 110.0 degrees Fahrenheit (F) and in the private bathroom, the water temperature measured at 109.7 degrees F.

Please continue to 809-C, Pg 2.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:
DATE: 10/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2024
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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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 VALLEY, INC.
FACILITY NUMBER: 565801596
VISIT DATE: 10/09/2024
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 The kitchen consists of a refrigerator, built in oven, stove top, microwave, toaster/convection oven, 4-slice toaster, and a blender. The kitchen cabinets, refrigerator, stove, and counters are clean. The facility is sufficiently stocked with at least two days of perishables and seven days of non-perishables. Snacks and beverages are available for residents in care upon request. Sharps are kept in a cabinet above the microwave oven located in the kitchen.
Cleaning agents are kept in a cabinet under the kitchen sink and in the garage. Medications are kept in a locked hallway closet. First aid supplies were observed to be in good order.
Residents participate at will in music activities, television watching, indoor exercise, and backyard visitations with family members and guests, bird watching, and relaxation. Activities outside the facility include excursions to local businesses, eateries, and scenic drives.
The front yard consists of a driveway, paved walk way and covered front porch leading to the front door. The backyard consists of a paved patio with sitting areas under a pergola, and plush planted shrubs and flowers. The recycling bin, green waste bin, and trash bins are standard bins with flip lids.
Personnel records were reviewed for trainings, health screenings, and background clearances. All personnel records are current. All staff are properly associated to the facility.
Residents’ records were reviewed for admission agreements, health screenings, and medications. All residents' records are current. Medications are given as prescribed.
LPA recommended the street number of the facility be made more visible for emergency purposes.

Exit interview conducted. No deficiencies noted. 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: 10/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024
LIC809 (FAS) - (06/04)
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