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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604325
Report Date: 06/17/2022
Date Signed: 06/17/2022 12:31:27 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/10/2022 and conducted by Evaluator Stephanie Torres
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220610130056
FACILITY NAME:MARAMAFACILITY NUMBER:
374604325
ADMINISTRATOR:SANDISON, HEATHERFACILITY TYPE:
740
ADDRESS:727 ASCOT DRIVETELEPHONE:
(760) 941-9208
CITY:VISTASTATE: CAZIP CODE:
92083
CAPACITY:12CENSUS: 10DATE:
06/17/2022
UNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Karrie Shotts, Director TIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Resident was illegally evicted
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to initiate the investigation into the above allegation. The LPA met with Karrie Shotts, Director, and informed her of the purpose of her visit.

On this visit the LPA conducted staff interviews, reviewed records and took copies of pertinent documentation. Regarding the allegation, "Resident was illegally evicted," it was alleged Resident One (R1) was evicted from the home through the means of a rate change. Director, Karrie Shotts, was interviewed and reported R1 was observed to have a change of condition and a rate change was proposed. Records review revealed a re-assessment was done for R1 on June 02, 2022 as a result of several hospitalizations in May 2022. The report was compared to the assessment done during admission, on April 09, 2021, and changes to the resident’s needs were observed. Hospital discharge paperwork and Unusual Incident Reports (UIRs) revealed R1 was hospitalized on several occasions in May 2022. In addition, staff interviews revealed R1 was observed to have
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2022
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 2
Control Number 18-AS-20220610130056
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: MARAMA
FACILITY NUMBER: 374604325
VISIT DATE: 06/17/2022
NARRATIVE
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a change of condition, to include changes with incontinence, ambulation, cognition, and Activities of Daily Living (ADLs). Interviews revealed R1 was not issued a written eviction notice and the rate of care was proposed, though not changed. It was revealed R1 was voluntarily transferred from the home on June 11, 2022. Based on this information, this allegation is deemed UNFOUNDED. A finding that the complaint is unfounded means the allegation is false, could not have happened, and/or is without a reasonable basis.

This report was reviewed with Shotts and a copy was provided.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2