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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 045000644
Report Date: 05/21/2025
Date Signed: 05/21/2025 04:41:57 PM

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
05/21/2025 and conducted by Evaluator Sarah Benson
COMPLAINT CONTROL NUMBER: 59-AS-20250521105015
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: 65DATE:
05/21/2025
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Rachel Hernandez Resident Care CoordinatorTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Staff do not ensure resident's medical needs are being met.
INVESTIGATION FINDINGS:
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05/21/2025 at 3:30 PM Licensing Program Analyst (LPA) Sarah Benson, conducted an unannounced visit and met with Rachel Hernandez Resident Care Coordinator. The purpose of this visit was to open a complaint investigation. During today's visit the facility was toured and interviews were performed.

LPA Benson requested the following documents during the visit: staff schedules with telephone numbers, residents admission agreement, medical record, medication record, physician reports, care plan and incident reports.


Continued on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Sarah BensonTELEPHONE: 530-895-5033
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2025
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 3
Control Number 59-AS-20250521105015
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: 05/21/2025
NARRATIVE
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During document review it was discovered that the resident has a prescription for blood sugar checks twice daily.

During interviews it was reported that the resident ran out of test strips 5-9-25. It was reported that the resident takes diabetic medication by mouth but no longer takes injectable insulin. It was reported staff attempted to get the refills from the pharmacy and physician. LPA Benson ask what the protocol is when unsuccessful and staff reported they just keep trying. LPA Benson inquired if the vendor was notified and staff stated, I’m not sure. Staff reported in the past the vendor has helped to get test strips.

Based on investigation observations and interviews which were conducted and record review(s), 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 an exit interview was conducted. If any of the cited deficiencies are not corrected by the noted due date, civil penalties may be assessed.




Continued on LIC9099-D
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Sarah BensonTELEPHONE: 530-895-5033
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 59-AS-20250521105015
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: 05/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/28/2025
Section Cited
CCR
87465(a)(4)
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The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The licensee shall assist residents with self-administered medications as needed. 87629 (2) Ensuring that sufficient amounts of medicines, test equipment, syringes, needles and other supplies are maintained in the facility and are stored as specified in Section 87465(c).
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The administrator agrees to develop a plan of correction to be submitted to the licensing agency advising how this type of deficiency will be avoided in the future.
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This requirement was not met as evidenced by: Based on interviews and records reviewed, the licensee/administrator did not ensure that a resident received his medication (test strips) when the medication was prescribed.
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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.
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Sarah BensonTELEPHONE: 530-895-5033
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3