Villa Mariposa Senior Care

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) De Leon arrived at 10:45 am to conducted a 1 year annual visit to the facility above. LPA met Administrator/Licensee Miriam and Hans Salamanca and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted with Administrator. The following was inspected and noted during the annual visit: Infection Control: The facility has a Infection Control Plan. The facility has a sign in and out binder for visitors at entry. The bathrooms have toilet paper, paper towels, hand soap, and hand washing signs. The facility has EPA approved disinfectants spray and cleaners. The facility has a 30 day supply of PPE. Quarantined or isolated individuals will have meals and medication delivered to rooms. Staff are trained on infection control and the use of Personal Protective Equipment (PPE). All trash cans and waste baskets have tight fitting covers. Physical Plant & Environmental Safety: The facility is a 3 bedroom and 2 bathroom currently occupying 3 residents and 2 Administrator. The facility is clean, safe and sanitary. LPA was authorized to enter and inspect facility. The facility has smoke and carbon monoxide detectors. The lighting and lamps are sufficient for the use of the facility and for residents comfort. The facility kitchen is clean, safe and sanitary. The showers have non-skid textured floors or mats present. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The pathways are clear of any obstructions. Facility is well lit inside and outside. Disinfectant, cleaning solutions and poisons are inaccessible to residents in care and locked in garage. The facility has sufficient space inside and outside for activities and visiting. The facility has a backyard/side yard and patio for resident use with plenty of shade. The facility has telephone and internet service for resident use. Continued 809-C Operational Requirements: The facility has a current plan of operation. The Facility is operating in compliance with the granted fire clearance. The facility has current liability insurance and expires on 12/30/2023. The facility is approved for a capacity of 6 Non-Ambulatory and has a current Hospice wavier granted for 2. The facility phone number has been changed and the new phone number is 805-619-7325. Staffing: The facility has two full-time Administrators on staff. Staff records are kept confidential. LPA reviewed 2 staff files for required forms and signatures, Files had 1stAid/CPR, LIC 501 Personnel Applications, LIC. 503 Health screenings with TB results, LIC 508 Criminal Record statements and fingerprint background Clearances, Transfers and Exemptions on file. Personnel Records & Training: The facility keeps confidential files for each staff member. LPA reviewed 2 Administrators files. Files have education/Training for renewal of Administrator Certificates present. 1 Administrator certificate expire on 09/22/2024 and 1 Administrator certificate is in the renewal process and was verified pending on Community Care Licensing (CCL)website . Administrator did not have documented Quarterly Drills and will provide records to CCL. Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Three files were reviewed for signed Admission Agreements, Medical Assessments, LIC. 602A Physicians Report, ID and Emergency contact forms, Appraisal Needs and Services plans (ANS), TB results, Personal Rights and Pre-Admission appraisals are conducted on perspective residents before accepting them into care. The Facility does not handle cash resources for any 3 residents in care. Facility does submit incident reports to the department when required. Resident Rights Information: All require postings were posted in the common area of the facility. Personal rights, Rights to Resident Council, Theft and Loss policy, and Non-discrimination notice. CCL Complaint poster and LTCO poster were posted in the entry area of facility. The current license along with CCL's last reports is on file. CCL PIN's were posted. Visitation policy is posted at entry. Internet is provided to residents with confidentiality and privacy. Planned Activities: The facility offers activities to all residents in care. The facility also offers additional activities to include books, magazines, newspapers, television, daily walks, group discussions, and puzzles. The facility has sufficient space to allow for activities indoors and outdoors. Continued 809-C Food Service: The facility handles and prepares food safely. The facility has 2 day perishables and 7 day non-perishables to meet the food service requirement. The freezer is kept at 0 degrees and the refrigeration is kept at 40 degrees or lower. All food is covered, stored and marked appropriately. Food, snacks and drinks are available when the residents want them. Emergency supply of food and water is available. A menu is posted for residents in care. Cleaning solutions and equipment are stored separately than food supply. Kitchen areas are kept clean and free from litter, rodents, vermin and insects. Kitchen staff are observed for personal hygiene and food sanitation practices. Incidental Medical & Dental: Facility provides transportation to medical and dental appointments when needed. Medication are kept in a locked cupboard in locked garage. LPA reviewed medication records with the Centrally Stored Medication Destruct Record and Medication Administrator Record. Doctors orders were present. Prescription and PRN Medications labels were not altered and medications were stored in original containers and no medications were expired. The facility has a locked box for any refrigerated medications. Disaster Preparedness: The current emergency disaster forms were present/posted. The facility conducts quarterly disaster drills. The fire extinguishers were charged and inspected. Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full facility in an emergency. The facility has an emergency food and water supply. The facility has an emergency binder with all required records present. Residents with Special Health Needs: The facility does accept dementia residents in care. All items that could pose a danger, sharps, cleaners were locked or in accessible to residents in care. The facility does not have delayed egress. The facility has 2 hospice residents in care. Hospice care plans are kept on file and up to date. The facility does not have any current residents on oxygen or Home Health Services. The facility has exiting door alarms. LPA conducted interviews with 2 Staff and 2 residents. Exit interview conducted and copy of report printed for Administrator.the state’s words, verbatim · CDSS document, Oct 12, 2023

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff left residents alone at the facility for an extended amount of time.

Licensing Program Analyst (LPA) De Leon conducted a 10-day complaint visit to the facility above. LPA met with Herbert Salamanca Licensee/Administrator of the facility and explained the purpose of the visit. LPA requested a staff roster with telephone numbers, a resident roster, 3 residents ID and emergency information forms and 3 residents physicians report (LIC 602A). Licensee/Administrator provided all documentation requested. At 1:15pm LPA toured the facility to check on the welfare of the 3 residents in care. On 09/15/2023 LPA interviewed Witness at 9:40am, Licensee/Administrator at 1:00pm, and residents at 1:20pm and 1:30pm. Continued 9099-C Substantiated On the allegation: Staff left residents alone at the facility for an extended amount of time. LPA conducted interviews with Witness which revealed on 09/13/2023 upon arrival about 1:08pm the facility did not have any staff present for a period of 45 minutes to 1 hour leaving 3 residents at the facility alone without supervision and staff returned to the facility around 1:50pm. LPA's interview with Licensee/Administrator revealed residents were left alone around 1:00pm after lunch Administrator went to CVS pharmacy to pick up resident medications then to a convenient store about a block and a half away from the facility to pick up a grocery item needed for dinner. Licensee/Administrator felt it was a bad judgment and was gone for only 15-20 minutes total. LPA interviewed residents which revealed 2 of 3 residents remembering being left alone, not sure of the exact date, it was a few days ago and the residents think it was for over 1 hour or so but more than 15-20 minutes. LPA reviewed 3 residents LIC. 602A Physicians Report according to those reports the facility has residents diagnosed with dementia, a resident on hospice services, a resident requiring 24/7 supervision, and a resident that can not leave the facility unassisted. Based on the evidence this allegation is Substantiated at this time. Exit interview conducted, deficiency cited, civil penalty assessed, copy of report and appeal rights printed for Licensee/Administrator.the state’s words, verbatim · CDSS document, Sep 15, 2023 · control 29-AS-20230914111545

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Sep 18, 2023

(f)Basic services shall at a minimum include:(1)Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by: Based on interviews, the licensee did not comply with the regulation above 3 residents were left alone without care and supervision for up to an hour which posed an immediate Health, Safety and Personal Rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 15, 2023

Plan of correction: Licensee agreed to review regulation 87464, write a statement of understanding on how the facility will prevent this from occurring again, provide an LIC 500 for staff, submit an incident report to the CCL and notify all residents responsible parties of the incident. Civil Penalty Assessed.

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) De Leon conducted a case management visit to the facility above to check on residents that relocated from Licensee prior facility and the current financial records for the facility. LPA met with Hans and Miriam Salamanca Licensee/Administrators and explained the purpose of the visit. LPA toured facility with Administrator. The residents were finishing breakfast upon LPA arrival. LPA checked on 2 residents that relocated and both were in positive moods and had no complaints. The facility had 2 day perishables and 7 day non-perishables to met the food requirements. The facility had toilet paper, paper towels, soap, laundry detergent and cleaning supplies. The facility was clean, safe and sanitary upon inspection. Community Care Licensing (CCL) requested documents on prior facility for a solvency audit for both facilities due to cancellation of Liability Insurance. LPA requested the following records: Current Business Bank Statement, Current Facility Mortgage Statement, Current Facility Utilities bills water, trash, PG&E, gas, and telephone to provide to LPA by 4:00 PM today. LPA emailed Licensee the following forms to complete and email back to LPA, LIC. 401, LIC. 401a, LIC. 403, LIC. 403a, and LIC. 404 by 02/20/2023 COB. Licensee provided an up to date copy of Liability Insurance on 01/03/2023 covering the facility above. Licensee stated the facility is not having any financial difficulties and has funds to keep the operation open and running with proper supplies. The licensee has a personal C-Train with a trailer that had to be moved from property and stored at an alternate location which is a personal issue and does not have anything to do with the Business/Facility. Exit interview conducted and copy report printed for Licensee/Administratorthe state’s words, verbatim · CDSS document, Feb 16, 2023

Type of visit: POC

Licensing Program Analyst's (LPA's) De Leon and Jeffries made an unannounced Plan of Correction visit.. LPA's met with Hans Salamanca back up to Administrator and explained the purpose of the visit. LPA's cited Licensee on 12/15/2022 for no liability insurance. LPA De Leon requested liability insurance on arrival and Back up to Administrator stated he has not been able to obtain valid liability insurance at this time. Mr. Salamanca stated he is working with a company to get new liability insurance and will need additional time to obtain. A civil penalty will be issued today for the plan of correction not being submitted. Exit interview conducted civil penalty assessed on 12/15/2022 809-D with appeal rights. LPA will email copy of report and appeal rights to the Licensee/Administrator.the state’s words, verbatim · CDSS document, Dec 22, 2022

Type of visit: Case Management - Other

Licensing Program analyst's (LPA's) De Leon and Jeffries conducted a case management visit to the facility above. LPA's met with Hans Salamanca and explained the purpose of the visit. LPA's reviewed medications for 2 residents in care. Medications matched MAR, CSMDR, and bottles. Exit interview conducted and copy of report emailed to Licensee/Administrator.the state’s words, verbatim · CDSS document, Dec 22, 2022

Type of visit: Case Management - Other

Licensing Program Analysts (LPA's) De Leon and Jeffries conducted a case management (CM) visit to the facility above. LPA's met with Staff, Licensee Herbert "Hans" Salamanca was unable to make the visit. LPA explained to staff the purpose of the visit. Community Care Licensing received United States Postal Service (USPS) mail from the facility insurance company that the Liability insurance was being cancelled for non-payment. LPA De Leon called Licensee on 11/21/2022 requested a new copy of liability insurance and Licensee explained at the time they were in the process of obtaining new insurance and it would be about 3 weeks before they could provide evidence of new insurance records. LPA De Leon requested a new copy of the facility liability insurance today and Licensee said they were in the process of obtaining but did not have any current records of proof of insurance. Licensee stated he could provide the paperwork of it being in process if needed. As of today 12/15/2022 the facility does not have current liability insurance. Exit interview conducted, deficiency cited, copy of report and appeal rights emailed to Licensee.the state’s words, verbatim · CDSS document, Dec 15, 2022

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.605 · Plan of correction due date: Dec 16, 2022

Liability insurance;...requirements.... all residential care facilities for the elderly..., shall maintain liability insurance covering injury to residents....This requirement was not met as evidence by: Based on interview the Licensee did not comply with the regulation above the facility does not have record of current liability insurance which posses an immediate, health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 15, 2022

Plan of correction: Licensee agreed to provide a current record of liability insurance meeting HSC requirements and provide a copy to the department.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) De Leon conducted an on site 1 year infection control annual visit to the facility above on 09/06/2022 at 11:30 AM. LPA met with Administrator Miriam Salamanca and explained the purpose of the visit. LPA took a physical plant tour of the facility with Administrator. The facility has submitted a mitigation plan to the department and it has been approved. The facility has an entry point at the front door where everyone entering completes sign-in, symptom questionnaire and temperature screening. All documentation is kept on a clipboard. The entry station has hand sanitizer along with a thermometer. The facility has a living room to accommodate activities, a dining room for dining, all areas are spaced to accommodate as much space as possible for social distancing. The facility has a large backyard with furniture, umbrella for shade and resident use. All equipment and PPE supplies are kept in the staff office. Medications are kept in a locked medication cabinets in the staff office. The staff screen residents for symptoms and temperature 1x's a day and documentation is kept on file. Increased monitoring is conducted if any change of condition is noted. Signs are posted on the front door, entry area and walls in common areas regarding Covid-19. Staff makes sure 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. Facility have areas for visiting inside and outside. The facility also offers virtual and telephone communications to all residents in care. Staff, Residents and visitors are informed of the facilities infection control policies. New staff and residents will be tested 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. Continued 809-C Emergency Disaster plan is posted and all agencies with telephone numbers are listed. Administrator is in charge of infection control and provides training and education to staff, residents and visitors. Administrator is in charge of staffing and works on any issues or additional coverage. If any suspected or confirmed cases of Covid-19 are found in the facility a staff will be assigned to work with those quarantined/isolated individuals. Staff will use full PPE with N95 masks, face shields and or googles when dealing with any pending or confirmed cases of Covid-19. Facility is able to dedicate a single room for resident so isolation can be arranged when and if needed. The facility has 3 resident bedrooms and 2 resident bathrooms and they are disinfected after use. Enhanced precautionary droplet signs will be posted on any room with quarantine or isolated individuals. PPE supplies will be located right 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. Sick staff are requested to stay home and not report to work if ill. 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 were well stocked with soap, paper towels and hand washing signs. Staff and resident records are kept in locked cabinets in the staff office. Facility does realize 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. No deficiencies observed during the visit and all infection control protocols are implemented and are being followed. Exit interview completed and copy of report emailed to Administrator/Licensee.the state’s words, verbatim · CDSS document, Sep 6, 2022

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) De Leon conducted a Case Management Health and Safety check on residents in care. LPA met with staff caregiver Virigina Ambos and explained the purpose of the visit. LPA took a tour of the inside of the facility. LPA observed 2 residents in care, neither resident had any concerns at the time. LPA's De Leon and Jeffries contacted the Licensee's facilities. The above facility did not answer and a voice mail was left with no one reply. LPA De Leon and Jeffries left voice mails on the facility cell phones on record with no response. LPA De Leon visited the facility to check on the resident's in care and to make sure the facility has a working telephone . The telephone on record was called by LPA De Leon and it did not ring in the facility. LPA De Leon used the facility phone to call LPA's cell number and it did place the cal but when calling the facility number came up differently and did not match the facility telephone on file. LPA De Leon will update the facility phone number on file. Exit interview conducted, no deficiency cited at this time, copy of report emailed to the Licensee/Administrator.the state’s words, verbatim · CDSS document, Sep 16, 2021

Type of visit: Office

An Informal Conference was conducted today in the Goleta Office. The purpose of the Informal Conference was to discuss deficiencies cited for the licensee’s three facilities (Miriam’s Place, Villa Mariposa Senior Care, and SingleTree Caring Hands). Present at today’s meeting were: Kelly Burley, Licensing Program Manager; Rachael De Leon, Licensing Program Analyst; Mark Jeffries, Licensing Program Analyst; Miriam Salamanca, Licensee/Administrator; Herbert Salamanca, Licensee/Administrator. The Informal Conference process was explained to the Licensee. The Licensee was notified that this Informal Conference is a part of the Administrative Action process and that further citations may result in Probation or a formal Non-Compliance Plan, which could then lead to a referral to the Department's Legal Division for possible Administrative Action. Today's conference addressed the following issues: - Repeat violations of the same regulation - Promptly submitting Plans of Correction (POCs) and other requested documentation - Medications must be locked, given as prescribed, the labels cannot be altered, medications must be logged properly on the Centrally Stored Medication Record. - Ensuring staff have fingerprint clearance before working - Staff must be trained adequately and it must be documented - Facilities must ensure sufficient staffing - Training of staff must be done and records must be kept current for all training of staff - Safety of residents with dementia; physical plant. - Proper supervision of residents so they do not elope Continued 809-C - Ensure staff wear proper PPE in the facility, including masks at all times. - Submit incident reports - Ensuring Licensees understands the importance of correcting previously cited violations. - Ensure annual fees are paid, as one facilities’ annual fees are not current. LPM will give until 8/17/2021 to have the following deficiencies corrected and provide proof to CCL: POC for postural supports/exception needed, and POC for training. Failure to fulfill the POC by this date will result in civil penalties for failure to correct. LPM Burley encouraged the Licensees to check the Provider Information Notices (PINs) on CCLD's website (www.ccld.ca.gov). LPM Burley also discussed the Licensees have been referred to the Technical Support Program, but later changed their mind and did not want to participate. LPM Burley encouraged Licensees to participate, as the Program is designed to help bring facilities into compliance. Licensee agreed to accept TSP services. Exit interview. Report giventhe state’s words, verbatim · CDSS document, Aug 10, 2021