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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604325
Report Date: 04/16/2024
Date Signed: 04/16/2024 03:11:09 PM


Document Has Been Signed on 04/16/2024 03:11 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:MARAMAFACILITY NUMBER:
374604325
ADMINISTRATOR:SANDISON, HEATHERFACILITY TYPE:
740
ADDRESS:727 ASCOT DRIVETELEPHONE:
(760) 505-3019
CITY:VISTASTATE: CAZIP CODE:
92083
CAPACITY:12CENSUS: 6DATE:
04/16/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:01 PM
MET WITH:Director Karrie ShottsTIME COMPLETED:
03:22 PM
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Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced visit regarding an open complaint that is currently under investigation. LPA was granted entry and met with Director Karrie Shotts during the visit.

During LPA's record review of the resident files, it was revealed Resident One (R1) Physician Report on file was last dated on 02/25/2023. LPA requested a Physician's Report 2024. Staff informed LPA an updated Physician's Report was not available for R1 for review. Residents diagnosed with Dementia must have an updated Physician's Report completed annually. A deficiency cited under Title 22 Regulation 87705(c)(5) Care of Persons with Dementia will be issued along with a plan of correction.

An exit interview was conducted where a copy of this report, LIC 809-D, and appeal rights was provided to Shotts.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 605-0913
LICENSING EVALUATOR SIGNATURE:
DATE: 04/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2024
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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Document Has Been Signed on 04/16/2024 03:11 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: MARAMA
FACILITY NUMBER: 374604325

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/26/2024
Section Cited
CCR
87705(c)(5)

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Care of Persons with Dementia: (c) Licensees...shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment...and a reappraisal done at least annually... This requirement was not met by:
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Licensee shall obtain an updated Physician's Report for R1 and submit a copy to LPA by the Plan of Correction date of 04/26/2024.
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Based on record review and interview, the Licensee did not comply with the above regulation with at least 1 of 6 residents (R1). Record review revealed R1's Dementia diagnosis and their last Physician's Report is dated 2/25/23. This is a potential health and safety risk to R1.
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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: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 605-0913
LICENSING EVALUATOR SIGNATURE:
DATE: 04/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2024
LIC809 (FAS) - (06/04)
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