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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 045000644
Report Date: 11/07/2025
Date Signed: 11/07/2025 11:02:54 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/02/2025 and conducted by Evaluator Sarah Benson
COMPLAINT CONTROL NUMBER: 59-AS-20250502113431
FACILITY NAME:MARBELLA CHICOFACILITY NUMBER:
045000644
ADMINISTRATOR:BLOW, SCOTTFACILITY TYPE:
740
ADDRESS:1351 E. LASSEN AVENUETELEPHONE:
(530) 899-0814
CITY:CHICOSTATE: CAZIP CODE:
95973
CAPACITY:79CENSUS: 66DATE:
11/07/2025
UNANNOUNCEDTIME BEGAN:
10:22 AM
MET WITH:Administrator Scott BlowTIME COMPLETED:
11:23 AM
ALLEGATION(S):
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Staff left resident on the floor for an extended period of time.
Staff did not administer resident's medication as prescribed.
Staff did not respond to resident's call button in a timely manner.
Staff did not ensure resident's call button is in good repair.

INVESTIGATION FINDINGS:
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On 11-7-25 Licensing Program Analyst (LPA) Sarah Benson, arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 05-02-25. LPA Benson met with Administrator Scott Blow and explained the purpose of the visit.

During the interview process, 7 staff persons were interviewed. The following documents were received and reviewed: staff schedules with telephone numbers, residents admission agreement, medical records, medication records, physician record's, communicable disease records, call button records, shower logs and incident reports.

Continued.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sarah Benson
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 7
Control Number 59-AS-20250502113431
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: MARBELLA CHICO
FACILITY NUMBER: 045000644
VISIT DATE: 11/07/2025
NARRATIVE
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Staff left resident on the floor for an extended period of time.

The resident stated I had fallen and for hours was yelling for help. It was reported that the resident could not get help and therefore called a family member. It was reported that the family member called the facility, reporting the fall to staff.


A staff person reported that a family member had called to notify them that R1 had fallen and was on the floor in their room. The resident reported falling, pushing device multiple times and yelling for help then scooting on the floor to retrieve cell phone to call a family member.
Record review revealed the devise activity reported the alarmed notice at 2:02A.M. activated and not cleared until 7:33A.M.

Staff did not administer resident's medication as prescribed.
It was reported on Saturday, April 12th, a family member went to visit R1 at 1P.M. The family member reported they had not given R1s morning medications. The family member reported the staff administered the medication shortly thereafter.

During interviews LPA Benson inquired with staff, if it is recorded when a medication is given late. Staff stated yes, I would make a note electronically. Staff stated the first couple weeks of April we were using a paper MAR so I may have given the medication late and not record that it was given late. Staff stated the paper MAR was harder to make notes, it took more time.


Based on investigation observations, record review(s) and interviews which were conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099D. Appeal rights were explained and provided to the facility representative listed above and exit interview conducted. If any of the cited deficiencies are not corrected by the noted due date, civil penalties may be assessed.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sarah Benson
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 59-AS-20250502113431
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MARBELLA CHICO
FACILITY NUMBER: 045000644
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/05/2025
Section Cited
CCR
87466
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Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs…
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Administrator will have all care staff receive training for shift change communication.
Administrator will notify LPA when completed.
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This requirement is not met as evidenced by: Based on interviews and records reviewed, the licensee/administrator did not ensure staff did not give appropriate assistance as a resident was on the floor for an extended period of time. Which poses a potential Health, Safety or Personal Rights risk to persons in care.
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Type A
12/05/2025
Section Cited
CCR
87465(a)(2)
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Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility... (2) The licensee shall provide assistance in meeting necessary medical and dental needs...
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Administrator will have all med. techs. receive medication training from an outside source.
Administrator will notify LPA when complete.

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This requirement is not met as evidenced by:
Based on interviews and records reviewed, the licensee/administrator did not ensure that a resident received her medication when the medication was prescribed. Which poses a potential Health, Safety or Personal Rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sarah Benson
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 59-AS-20250502113431
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MARBELLA CHICO
FACILITY NUMBER: 045000644
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/05/2025
Section Cited
CCR
87411(a)
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Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by:
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Administrator will verify all call buttons are responded to in a timely manner.
Administrator will have a training for all care staff concering call button response and clearing.
Administrator will notify LPA when complete.
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Based on interviews and records reviewed, the licensee/administrator did not ensure a resident was attented to in a timely manner. Which poses a potential Health, Safety or Personal Rights risk to persons in care.
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Type B
12/05/2025
Section Cited
CCR
87303(i)(B)
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Maintenance and Operation
(i) Facilities shall have signal systems which shall meet the following criteria:
(1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: (B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff.

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Administrator will create a maintenance repair log for call button repairs.
Administrator will verify all call buttons are in working order.
The facility is getting a new call system.
Administrator will notify LPA when complete.
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This requirement is not met as evidenced by: Based on interviews and records reviewed, the licensee/administrator did not ensure the call button was in working order. Which poses a potential Health, Safety or Personal Rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sarah Benson
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 59-AS-20250502113431
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: MARBELLA CHICO
FACILITY NUMBER: 045000644
VISIT DATE: 11/07/2025
NARRATIVE
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Staff did not respond to resident's call button in a timely manner.
During staff interviews, multiple staff reported on 4-30-25 R1’s bath room call button was not working.
Record review revealed the devise activity reported the alarm at 2:02A.M. as activated and not cleared until 7:33A.M.
It was reported; a family member had notified staff that R1 had fallen in their room and staff were unaware. It was reported the night shift reported to the morning shift that R1 was good, although the resident had fallen, pushed the call button and no help arrived in a timely manner.

Staff did not ensure resident's call button is in good repair.

Staff stated the resident returned to the facility on April 30, 2025 and I verified with a family member that the wall alarm in the bathroom was not working. Staff stated the system will tell us when it is not working. Staff reported the system will signal when it (needs a new battery) and the maintenance guy is responsible for replacing/fixing the call system. Staff stated on 4-30-25 one of R1’s call buttons was not working, I can’t remember if it was the bed or bathroom, the pendent R1 was wearing was working. Record review revealed at times the call button recorded a room downstairs sending the alarm instead of the actual room.





Based on investigation observations, record review(s) and interviews which were conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099D. Appeal rights were explained and provided to the facility representative listed above and exit interview conducted. If any of the cited deficiencies are not corrected by the noted due date, civil penalties may be assessed.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sarah Benson
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/02/2025 and conducted by Evaluator Sarah Benson
COMPLAINT CONTROL NUMBER: 59-AS-20250502113431

FACILITY NAME:MARBELLA CHICOFACILITY NUMBER:
045000644
ADMINISTRATOR:BLOW, SCOTTFACILITY TYPE:
740
ADDRESS:1351 E. LASSEN AVENUETELEPHONE:
(530) 899-0814
CITY:CHICOSTATE: CAZIP CODE:
95973
CAPACITY:79CENSUS: 66DATE:
11/07/2025
UNANNOUNCEDTIME BEGAN:
10:22 AM
MET WITH:Administrator Scott BlowTIME COMPLETED:
11:23 AM
ALLEGATION(S):
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Staff did not prevent the spread of a communicable disease.
INVESTIGATION FINDINGS:
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During the interview process it was reported by seven staff members protocol to prevent the spread of a communicable disease was followed during the outbreak in April 2025. Staff seven S7 reported we set up PPE outside of each resident’s room, place a sign of outbreak at resident’s door, notify all staff. Staff reported a notice was placed on the front door of outbreak and a notice to wear a mask was posted. Staff reported It was posted on the entrance doors and on the infected residents’ doors. Staff stated we contacted the county nurse, and CCL. Staff reported as soon as we knew we had someone with the virus, it was posted. Staff stated we then developed a plan to contain the spread of the disease such as hand hygiene, contact protocol and staff reminders. Record review revealed an outbreak was reported in April 2025 to CCL.

Based on the interviews conducted the allegation is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sarah Benson
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/02/2025 and conducted by Evaluator Sarah Benson
COMPLAINT CONTROL NUMBER: 59-AS-20250502113431

FACILITY NAME:MARBELLA CHICOFACILITY NUMBER:
045000644
ADMINISTRATOR:BLOW, SCOTTFACILITY TYPE:
740
ADDRESS:1351 E. LASSEN AVENUETELEPHONE:
(530) 899-0814
CITY:CHICOSTATE: CAZIP CODE:
95973
CAPACITY:79CENSUS: 66DATE:
11/07/2025
UNANNOUNCEDTIME BEGAN:
10:22 AM
MET WITH:Administrator Scott BlowTIME COMPLETED:
11:23 AM
ALLEGATION(S):
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Staff does not ensure resident's showering needs are being met.
INVESTIGATION FINDINGS:
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Document review revealed, R1 refused a shower on 4-24-25 and on 4-28-25 3 times with change of face. The facility has record of offering showers at different times of the day also.
During staff interviews, multiple staff stated R1 would say she was in too much pain. Staff stated R1 refused showers most of the time, more times than not. Staff can not force a resident to shower.
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Based on the interviews conducted the allegation is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sarah Benson
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 7 of 7