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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045000603
Report Date: 02/06/2025
Date Signed: 02/06/2025 11:20:00 AM

Document Has Been Signed on 02/06/2025 11:20 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:MARBELLA OROVILLEFACILITY NUMBER:
045000603
ADMINISTRATOR/
DIRECTOR:
LAINE, KRISTIEFACILITY TYPE:
740
ADDRESS:400 EXECUTIVE PARKWAYTELEPHONE:
(530) 534-8160
CITY:OROVILLESTATE: CAZIP CODE:
95966
CAPACITY: 88TOTAL ENROLLED CHILDREN: 0CENSUS: DATE:
02/06/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Jay Tippens - Resident Care DirectorTIME VISIT/
INSPECTION COMPLETED:
10:00 AM
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02/04/2025 10:00 AM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with Resident Care Director Jay Tippens. Today’s visit is regarding a death report that was received by licensing on 01/28/2025.

It was reported that on 01/24/2025 Resident 1 (R1) was showing signs of stomach pain by clenching their stomach, and R1 would not attend lunch. Staff called 911 to come to the facility and evaluate R1. EMS transported R1 to Oroville Hospital via ambulance. R1 was admitted for peritonitis and kidney failure and passed away at Oroville Hospital on 01/26/2025.

During the investigation it was learned that during a home health visit the RN determined that R1 had a low heart rate. R1 was taken to their primary care doctor who ran labs and referred R1 to a specialist cardiologist. R1 saw the specialist for one visit and the specialist scheduled a follow-up visit. Before R1 attended the follow up visit they became acutely ill, were hospitalized and passed away in the hospital.

No deficiencies were cited as a result of today’s visit. Exit interview conducted and a copy of the report was provided to with Resident Care Director Jay Tippens.

Lauren CrockerTELEPHONE: (916) 261-4966
Rebecca KnightTELEPHONE: (530) 356-2841
DATE: 02/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/06/2025
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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