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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801596
Report Date: 09/24/2026
Date Signed: 09/24/2026 06:10:35 PM

Document Has Been Signed on 09/24/2026 06:10 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:MARIPOSA VALLEY, INC.FACILITY NUMBER:
565801596
ADMINISTRATOR/
DIRECTOR:		KARINA RAMIREZ VAZQUEZFACILITY TYPE:
740
ADDRESS:8217 TIARA ST.TELEPHONE:
(805) 659-4603
CITY:VENTURASTATE: CAZIP CODE:
93004
CAPACITY: 6CENSUS: 6DATE:
09/24/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Karina Ramirez VazquezTIME VISIT/
INSPECTION COMPLETED:
06:00 PM
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Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced required Annual Inspection at the above-named facility. LPA was greeted by staff. Administrator Karina Ramirez Vazquez was contacted via telephone and arrived at approximately at 09:20 AM. LPA explained the purpose of the visit. Entrance interview conducted.

RECORD REVIEW: At 09:40 a.m. a review of facility files was initiated. The LPA was not able to review their Infection Control Plan, Emergency Disaster Plan, or when they conducted their last emergency drill as the Administrator revealed that they misplaced them. Administrator revealed the facility did not have a current liability insurance. The LPA obtained a Client Roster and Staff Roster. The LPA reviewed five (5) out of six (6) resident files and five (5) out of five (5) staff files. All staff files were not at the facility, however the Administrator was able to get the additional staff files. The following was observed: Two residents did not have a pre-admission appraisal or care plans on file, two residents did not have their care plans signed by the resident and their responsible party, one resident did not have an updated care plan on file, two residents did not have their personal rights on file, one resident did not have an updated medical assessment, and one resident did not have their Admission Agreement signed by the resident or responsible party. All Staff did not have any current training on file, upon observation the owner revealed they had not conducted the training. One staff did not have a first aid/CPR training on file. Administrator revealed the staff had not conducted the training.

INTERVIEWS: LPA interviewed three (3) residents. No concerns noted.

Report will continue on LIC809-C (2ND PAGE).

Kasandra Lopez
Esther Cortez
DATE: 09/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/24/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: MARIPOSA VALLEY, INC.
FACILITY NUMBER: 565801596
VISIT DATE: 09/24/2026
NARRATIVE
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The facility is a one-story home located in a residential area. The LPA along with the Administrator toured the facility inside and outside to ensure resident health and safety and the facility is in compliance with Title 22 regulation. Various smoke alarms and carbon monoxide detectors were tested and functioned properly. The fire extinguisher was purchased 10/13/2025 and appeared fully charged.

BEDROOMS: The facility has 4 (four) bedrooms total; 2 (two) are shared resident rooms and 2 (two) are private rooms. All resident bedrooms were observed to be furnished properly. All resident rooms had appropriate bedding. There is an ample supply of linens and towels stored in the cabinets in the hallway.

RESTROOMS: The facility has three (3) full bathrooms for resident and staff use. All restrooms contained grab bars and slip-resistant surfaces. Hot water was measured within the required range.

COMMON AREAS: Paint, windows, blinds, and floors are in good repair. The common living and dining areas are clean and properly furnished. A working telephone is present. There is one (1) fireplace in the residence, which was properly screened at the time of the visit. Chemicals are stored locked under the kitchen sink and in the locked entry closet. The LPA observed a camera in the entry hallway, and one in the corner of the dinning room and one in the ceiling corner in front of the kitchen.



KITCHEN: The facility has a sufficient supply of non-perishable food, perishable food and an emergency supply of water is present. Knives are stored in a locked cabinet. Cleaning supplies were observed locked in a cabinet under the sink. The refrigerator/freezer was at the appropriate temperature (40*F and 0*F).

OUTDOOR SPACE: Building and grounds are free from hazard. Patio area observed outdoor shaded seating area for resident use. There is a water fountain in the backyard with sufficient pebbles inside. Both outdoor exit gates were observed to be self-closing and self-latching.

Report will continue on LIC809-C, 3rd page.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Esther Cortez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2026
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: MARIPOSA VALLEY, INC.
FACILITY NUMBER: 565801596
VISIT DATE: 09/24/2026
NARRATIVE
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MEDICATION REVIEW: Medications for two (2) residents were reviewed and observed stored properly in a locked closet. A medication audit for Resident 1 (R1) revealed that the start dates recorded on the Centrally Stored Medication and Destruction Record (CSMDR) did not match the actual start dates listed on the medication bubble packs. The LPA observed future start dates pre-recorded on the CSMDR for dates that have not yet occurred. The Administrator admitted to pre-documenting the CSMDR based on estimated medication counts, acknowledging that they frequently fail to correct the record if the medication is ultimately started on a different day. The LPA reviewed best practices with the Administrator, emphasizing that start dates must only be documented after the medication has actually been administered to prevent regulatory discrepancies.

A medication audit for Resident 2 (R2) revealed that all start dates were missing from the CSMDR. The Administrator stated that R2 began all bubble pack medications on the 1st of the month but failed to log these dates on the record. Furthermore, specific medication discrepancies were noted: Sertraline 25mg: A pill remained in the slot for the 15th of the month, indicating a missed dose. Quetiapine 25MG (Bedtime): Bubbles #24 and #25 were observed to be empty. Because the audit was conducted during the day on the 24th of the month, bubble #24 (tonight's bedtime dose) and bubble #25 (tomorrow's bedtime dose) should have still been present in the pack. The empty slots indicate that these medications are unaccounted for. The Administrator could not provide an explanation for the missed, missing, or unaccounted-for medications.



Pursuant to Title 22 CA Code of Regulations, the following deficiency was cited (refer to LIC809 -D).

Exit interview conducted. A copy of today's report and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Esther Cortez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2026
LIC809 (FAS) - (06/04)
Page: 16 of 16
Document Has Been Signed on 09/24/2026 06:10 PM - It Cannot Be Edited


Created By: Esther Cortez On 09/24/2026 at 05:06 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MARIPOSA VALLEY, INC.
FACILITY NUMBER: 565801596

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in two medications, medication audit indicated R2 had one missed dose for one medication, and two pills that were unaccounted for from a different medication which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/28/2026
Plan of Correction
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Administrator agreed to conduct a medication audit for all of the resident's and correct any errors on the Centrally Stored Medication and Destruction Record and will contact R2's primary care physician (PCP) to report the missed dose of Sertraline 25mg and the two missing bedtime doses of Quetiapine. Documentation of this contact will be placed in the resident's file. Proof of audit and contact will be submitted to LPA BY 09/28/26.
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.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Esther Cortez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/24/2026 06:10 PM - It Cannot Be Edited


Created By: Esther Cortez On 09/24/2026 at 05:06 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MARIPOSA VALLEY, INC.
FACILITY NUMBER: 565801596

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(c)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as they did not have an indection Contro Plan on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/02/2026
Plan of Correction
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Administrator agreed to complete an Infection Control Plan and submit to LPA by 10/02/26.
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 record review, the licensee did not comply with the section cited above as they do not have a current liability insurance which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/02/2026
Plan of Correction
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Administrator agreed to obtain and email proof to LPA of liability insurance required by regulations (HSC 1569.605) by 10/02/26.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Esther Cortez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2026


LIC809 (FAS) - (06/04)
Page: 7 of 16
Document Has Been Signed on 09/24/2026 06:10 PM - It Cannot Be Edited


Created By: Esther Cortez On 09/24/2026 at 05:06 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MARIPOSA VALLEY, INC.
FACILITY NUMBER: 565801596

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(1)
Other Provisions
(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as the Administrator admitted all staff did not have their annual training and did not have any proof of training for new staff which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/02/2026
Plan of Correction
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Administrator agreed that all staff would obtain all of the required initial or annual training needed and submit proof of training by 10/02/26.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Esther Cortez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2026


LIC809 (FAS) - (06/04)
Page: 8 of 16
Document Has Been Signed on 09/24/2026 06:10 PM - It Cannot Be Edited


Created By: Esther Cortez On 09/24/2026 at 05:06 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MARIPOSA VALLEY, INC.
FACILITY NUMBER: 565801596

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87457(c)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in two residents files that did not have an pre admission appraisal or care plan, 2 residents did not have signed current appraisals, and 1 resident did not have an updated appraisal on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/02/2026
Plan of Correction
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Administrator agreed to conduct a resident file audit for all residents and ensure all required documents, signatures, appraisals, and or care plans are complete and current. Proof to be submitted by 10/02/26.
Type B
Section Cited
HSC
1569.69(a)(2)
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment. This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 5 staff that did not have either annual or initial medication training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/02/2026
Plan of Correction
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Administrator agreed all staff will obtian the required annual or initial medication required training and submit proof of training by 10/02/26.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Esther Cortez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2026


LIC809 (FAS) - (06/04)
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