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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801596
Report Date: 10/24/2023
Date Signed: 10/24/2023 03:31:47 PM


Document Has Been Signed on 10/24/2023 03:31 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:
10/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator Karina Rameirez VazquezTIME COMPLETED:
02:12 PM
NARRATIVE
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 At 10:00am on 10/24/2023, Licensing Program Analyst (LPA) Jeffries arrived unannounced at the facility to conduct the annual inspection. LPA met with Administrator Karina Rameirez Vazquez, announced who he was and the reason for the visit.
At 10:30am, Staff 2 (S2) conducted a cursory tour of the facility. LPA noted that the facility was clean and in good repair. LPA noted that the back yard had chars and a pergola for shade for residents use. LPA noted that the medications were locked in closet near front entrance. LPA noted that there are combination smoke and carbon monoxide detectors in every room of the facility. LPA noted that the fire extinguisher in the kitchen was primed in the green, LPA observed resident bedrooms meeting all regulations requirements including linin, lighting and storage. LPA noted that a sample medication audit was conducted during the facility tour and found centrally stored medication log to be accurate. LPA observed at least 2 days of perishable foods and at least 7 days of non-perishable foods. LPA noted that the bathroom door at the end of the hallway required adjustment, Licensee contacted contractor during visit to have bathroom door adjusted to fit and will follow up with LPA next day (10/25/23) of repair. LPA conducted a sample review of resident files and a sample review of staff files and found files to be complete per regulations. LPA noted that the facility was clean and in good repair, and no passage ways, exit and doors were free of obstacles and were not blocked.
At 11:30am Licensee and LPA conducted a full review and the annual care tools. Upon review one citation was noted: Laps of liability Insurance. No other violations, citations or technical were found during the full review of care tools. At this time there is one citation issued as a result of the annual inspection.

Exit interview, citation issued, appeal rights and report provided.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2023
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 10/24/2023 03:31 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 VALLEY, INC.
FACILITY NUMBER: 565801596

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/07/2023
Plan of Correction
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Licensee to obtain and email proof to LPA at mark.jeffries@dss.ca.gov of liability insurance required by regulations (HSC 1569.605) by November 7, 2023
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2023
LIC809 (FAS) - (06/04)
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