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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045000603
Report Date: 03/13/2025
Date Signed: 03/13/2025 02:17:33 PM

Document Has Been Signed on 03/13/2025 02:17 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
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: 88CENSUS: 44DATE:
03/13/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Jaluisa Tippens - Resident Care DirectorTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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03/13/2025 01:30 PM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with Jaluisa Tippens - Resident Care Director. Today’s visit is regarding an incident report that was received by licensing on 03/10/2025 regarding an incident that occurred on 03/05/2025.

It was reported that on 03/05/2025 9:00 AM staff reported that Resident 1 (R1) was observed on the floor of their room in front of their recliner. R1 stated they were attempting to open their blinds when they lost their balance. R1 complained of pain to their left hip. EMS was called to evaluate and transported R1 to local hospital. R1 was diagnosed with fracture to their left hip and admitted to hospital. Resident was subsequently admitted to skilled nursing for rehabilitation.

During the investigation it was learned that staffing was sufficient when R1 fell. Staff had just removed their breakfast tray and exited the room. R1 lost their balance and fell. R1 is in rehab and their doctor and family have decided to keep them in long term care. If R1 recovers they plan to bring R1 back to the facility as R1 would like to come back.

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

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE: DATE: 03/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/13/2025
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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