425802106-8-4-2022-29-AS-KKOS-CGZ44D-20220804184610

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425802106
Report Date: 08/04/2022
Date Signed: 08/04/2022 06:47:01 PM

Document Has Been Signed on 08/04/2022 06:47 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 SHORES		FACILITY NUMBER:	425802106
ADMINISTRATOR:	PETER JOHN BONILLA		FACILITY TYPE:	740
ADDRESS:	190 VIAJERO DR		TELEPHONE:	(805) 265-4327
CITY:	GOLETA	STATE: CA	ZIP CODE:	93117
CAPACITY:	99	CENSUS: 80	DATE:	08/04/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Peter Bonilla, Administrator		TIME COMPLETED:	07:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPAs) Jeannette Olson and Kristin Kontilis conducted an unannounced on-site one-year Infection Control Inspection visit to the above-named facility. LPA arrived at 12:00 pm and was greeted by Staff 1 (S1). Administrator Peter Bonilla and Interim-Administrator Mark Cortes were present at the time of arrival. There were 59 residents in care in the Assisted Living unit with 1 medication technician and 3 caregivers on duty. In the “Compass Rose” Memory Care unit, there were 21 residents with 1 medication technician, two caregivers, and 1 activities coordinator on duty. The Compass Rose Resident Services Director who currently oversees the Assisted Living and Memory Care units of the facility was also on duty. A Mitigation Plan has been submitted to CCLD. LPAs explained the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE) and is home to non-ambulatory residents with a dementia diagnosis. There are 18 residents currently on hospice. Entrance interview conducted: The physical environment was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, and doors were checked. The facility was seen to be in good repair inside and outside. Throughout the facility, there are approximately 10 fire extinguishers and 5 fire pull alarms. The pull fire alarms alert the local fire department when activated. Fire inspection was most recently conducted on 6/17/2022 and 6/21/2022. There are approximately 81 dual carbon monoxide detectors and smoke alarms throughout the facility. The kitchen area was sufficiently stocked with two-day perishables and seven days of non-perishables. Snacks and beverages are readily available for Residents. LPA observed the dining areas are clean. LPA observed kitchen cabinets, refrigerator, stove, and counters are clean. Medications and First Aid supplies/kits are kept in locked cabinets in the Assisted Living nurse’s station and in the Memory Care nurse’s station. Please continue to 809-C, Pg 2.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022

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 AT ELLWOOD SHORES	FACILITY NUMBER: 425802106
	VISIT DATE: 08/04/2022

NARRATIVE

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Assisted Living Residents participate in activities such as special occasion celebration, music entertainment, Boce ball court, physical therapy, and excursions to local eateries and retail businesses. Memory Care residents participate in activities such as special occasion celebrations, music entertainment, and scenic drives.
The facility has various sitting areas throughout the first and second floors including a library/reading area, faux fireplace, computer/business center for residents and staff, vending machines, beauty salon, physical therapy center, and a laundry room.
The facility grounds are well maintained with walkways, sitting areas with covered tables and chairs, and raised garden areas. Throughout the interior area and outdoor area, the facility is conducive for socially distanced visitation.
Chemicals and cleaning supplies are kept in two locked closets with no access to residents in care.
The facility maintains a comfortable temperature. Hallways, bedroom doors, and walls are in good repair.
The facility has an entry point at the front door where residents, visitors, staff entering complete sign-in, symptom questionnaire and temperature screening. All documentation is kept in a file located at the front desk then later filed. The entry station has hand sanitizer along with a thermometer. All equipment and PPE supplies are kept in the Resident Services office and in a storage closet.
Residents are screen for symptoms and temperature at least once a day and documentation is kept on file. Increased monitoring is conducted if any change of condition are noted or any residents are showing any signs, symptoms or a temperature.
Signs are posted on the front door, entry area regarding COVID-19. Staff ensures that residents have a mask when leaving the facility on outings into the community.
All staff wear face coverings in the facility and when on outings with residents. The facility offers virtual and telephone communications to all residents in care.
Residents, staff, and visitors are informed of the facility’s infection control policies. New residents and staff will be tested for COVID-19 and negative results received before working or residing in the facility.
The facility has procedures and plans for screening, isolation, testing, when to call 911, and notifying all responsible parties and agencies when needed.
Emergency Disaster plan is posted and all agencies with telephone numbers are listed.
Administrator/Interim Administrator is in charge of infection control and provides training and education to staff, residents and visitors.
Please continue to 809-C, Pg 3.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022

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 AT ELLWOOD SHORES	FACILITY NUMBER: 425802106
	VISIT DATE: 08/04/2022

NARRATIVE

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If any suspected or confirmed cases of COVID-19 are found in the facility a staff will be assigned to only work with those quarantined/isolated individuals and will not work with other negative individuals until cleared by Health Department. Staff will use full PPE with N95 masks and face shields when dealing with any pending or confirmed cases of COVID-19. A single room can be dedicated with resident(s) who are suspected or tested positive with COVID-19. The facility has single rooms with restrooms and they are disinfected bi-weekly or daily in Memory Care. Precautionary Droplet signs will be posted on any room with quarantine or isolated individuals. PPE supplies will be located immediately outside those rooms when required. Facility has a 30-day supply of PPE on hand. Facility has plans for delivering medications and meals to any quarantined/isolation resident room.
The facility has proper cleaning and disinfectant sprays. Facility Administrator has a plan in place for when and whom to notify in an outbreak or other emergencies. Administrator will keep a line list of all vaccinated and tested staff/residents in care with dates/results.
Facility has conducted training on infection prevention, symptoms, transmission and PPE use. Facility has non-punitive sick leave polices for staff. Staff who have a respiratory illness are requested to stay home and not report to work.
Activities have been modified to individuals or small groups with social distancing. Residents medication is delivered in 30-day supplies to the facility. The facility ensures proper cleaning is done on frequently touched surfaces and between any individuals sharing of space or items.
Sinks are well stocked with soap, paper towels and hand washing signs. Staff and resident records are kept in locked office. Facility observes guidance changes and the most up-to-date guidance from CCL-PINS, CDC, CDPH, and local health departments should be followed to remain in compliance. The most stringent orders should be followed by any of these agencies. Administrator Certificate is valid.
At approximately 3:01 pm, LPAs reviewed Department of Social Services, Community Care Licensing Division, Licensing Information System (LIS), Facility Personnel and facility staff roster and determined there are 8 staff members currently working in the facility and have not been associated to the facility prior to their employment. Additionally, one staff member has not received a criminal background and/or fingerprint clearance and last worked in the facility on 8/4/2022.
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. Report and Appeal Rights issued via email.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/04/2022 06:47 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: 08/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Request Denied

Type A

Section Cited

CCR

87355(1)(2)

87355(e)(1) Criminal Record Clearance. (e) All individuals subject to a criminal record review...shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or criminal record exemption... or (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	This requirement is not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above as eight (8) facility staff were not associated to work in the facility and one (1) facility staff did not receive a fingerprint clearance and/or background check prior to working in the facility which poses an immediate health and safety risk to residents in care.
	POC Due Date: 08/05/2022
	Plan of Correction
1 2 3 4	Licensee agrees that staff members will not work at this facility without an appropriate transfer and/or receiving a criminal background/fingerprint clearance. Civil Penalty assessed in the amount of $4,750.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022

LIC809 (FAS) - (06/04)

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