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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 045002120
Report Date: 07/11/2025
Date Signed: 07/11/2025 11:03:11 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
05/22/2025 and conducted by Evaluator Rebecca Knight
COMPLAINT CONTROL NUMBER: 59-AS-20250522161516
FACILITY NAME:TRES MARIAS CARE HOME IFACILITY NUMBER:
045002120
ADMINISTRATOR:DEVILLA, MARIAFACILITY TYPE:
735
ADDRESS:2153 4TH STREETTELEPHONE:
(530) 532-7508
CITY:OROVILLESTATE: CAZIP CODE:
95965
CAPACITY:6CENSUS: 4DATE:
07/11/2025
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Maria Devilla - administratorTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Failure to seek timely medical attention - SUBSTANTIATED
INVESTIGATION FINDINGS:
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07/10/2025 09:30 AM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with administrator Maria Devilla and staff Boneface Negrillo. The purpose of this visit was to deliver the results of a complaint investigation.

During the course of the investigation LPA conducted interviews and reviewed the following documents: Admission Agreement, IPP, Physician’s Report, care plan, recent medical visit documentation for 1 client.

Continued on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:

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

DATE: 07/11/2025
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 4
Control Number 59-AS-20250522161516
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: TRES MARIAS CARE HOME I
FACILITY NUMBER: 045002120
VISIT DATE: 07/11/2025
NARRATIVE
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Failure to seek timely medical attention – SUBSTANTIATED

It was reported that Client 1 (C1) attended day program and their arm appeared red, swollen, warm to the touch, weeping yellow fluid.

LPA reviewed an incident report dated 05/02/2025 that was submitted by the day program that C1 attends. This incident report states that C1’s !eft arm appeared red, swollen, weeping yellow fluid and was warm to the touch. Staff noted that C1’s right arm had multiple scabs. Day program staff reported this to C1’s care home.

On 05/28/2025 LPA observed multiple lesions on Client 1’s (C1’s) arms. The lesions appeared to be dry and healing.

On 05/28/2025 C1 stated they were not being treated by a doctor for the wounds and the last time they saw a doctor was four months ago.

On 05/28/2025 day program staff stated the client has had the wounds for at least a month.

On 05/28/2025 administrator stated the wounds were a result of an allergy the client has been being treated for since 2004. The client has had the current rash for two weeks.

LPA reviewed a Physician’s Report for C1 dated 03/19/2025 which states that C1 is allergic to pollen.

LPA reviewed a physical exam dated 03/19/2025 which states that C1 has been prescribed the following medications which can be used to manage allergies and allergic reactions: Loratadine, Prednisone.

Continued on LIC9099-C

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:

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

DATE: 07/11/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 59-AS-20250522161516
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: TRES MARIAS CARE HOME I
FACILITY NUMBER: 045002120
VISIT DATE: 07/11/2025
NARRATIVE
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LPA reviewed medical appointment notes dated 05/29/2025 which state that C1 is allergic to pollen and dust. The reason for the visit was a rash on C1’s arm. Diagnosis: Healing lesions on left arm. Treatment plan: Use Mupirich cream twice a day until resolved. Mupirich Ointment is an antibiotic medicine used to treat certain skin infections such as impetigo (red sores), recurring boils, and others. LPA reviewed discharge prescription dated 05/29/2025 for MUPIROCIN 2 % OINTMENT which is not used to treat allergies but is used to treat bacterial skin infections.

It was determined that facility staff were made aware of C1’s condition on 05/02/2025 by day program staff but did not take the client in for medical treatment until 05/29/2025 after this complaint was opened. The allegation failure to seek timely medical attention is substantiated.

Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview conducted and a copy of the report was provided to administrator Maria Devilla.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:

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

DATE: 07/11/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 59-AS-20250522161516
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: TRES MARIAS CARE HOME I
FACILITY NUMBER: 045002120
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/25/2025
Section Cited
CCR
80075(a)
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80075(a) Health Related Services (a) The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services. This requirement was not met as evidenced by:
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Licensee agrees to conduct staff training on the requirement to seek timely medical attention for clients in care.
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Based on interviews and records review the licensee failed to ensure that 1 of 4 clients recieved timely medical attention for open sores on their arms.
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Licensee shall submit training materials and staff attendance sheet as proof of correction.
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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: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:

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

DATE: 07/11/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4