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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 11:21:13 AM

Document Has Been Signed on 02/06/2025 11:21 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: 42DATE:
02/06/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Jay Tippens - Resident Care DirectorTIME VISIT/
INSPECTION COMPLETED:
11:00 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 an incident report that was received by licensing on 01/16/2025 regarding an incident that occurred on 01/09/2025.

It was reported that on 01/09/2025 8:00 PM staff reported that Resident 1 (R1) was observed on the floor of their room. R1 expressed pain in left shoulder. EMS was called to evaluate and transported R1 to Oroville hospital. R1 was diagnosed with fracture to ribs and left shoulder and admitted to Oroville Hospital. Resident was subsequently admitted to skilled nursing for rehabilitation.

During the investigation it was learned that staff does rounds and checks on assisted living residents at 2:00 PM, 4:00 PM, 6:00 PM, 8:00 PM, and 10:00 PM. R1 was brought tray service to their room at approximately 6:30 PM that night. R1 was observed on the floor of their room during 8:00 PM rounds. Staff followed all fall protocols, since R1 complained of shoulder pain staff did not move R1 and called EMS. R1 is still in skilled nursing for rehabilitation. Facility staff are visiting R1 at SNF once per week to assess R1's condition. LPA inspected R1's room and no trip hazards were noted.

No deficiencies were cited as a result of today’s visit. Exit interview conducted and a copy of the report was provided to 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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