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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425801937
Report Date: 11/30/2021
Date Signed: 11/30/2021 03:13:58 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:MARAVILLAFACILITY NUMBER:
425801937
ADMINISTRATOR:GRANDE, RUTH EFACILITY TYPE:
740
ADDRESS:5486 CALLE REALTELEPHONE:
(805) 967-1965
CITY:SANTA BARBARASTATE: CAZIP CODE:
93111
CAPACITY:131CENSUS: 91DATE:
11/30/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Christina Martinez, Director of Enliven (MC), LVNTIME COMPLETED:
03:20 PM
NARRATIVE
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Licensing Program Analyst's (LPA's) De Leon and Kontilas conducted a case management visit to the facility above regarding an email from the administrator reporting the death of a resident in care on 11/26/2021. LPA's met with Staff Christina Martinez, director of Enliven Memory Care at Maravilla and explained the purpose of the visit. Administrator Ruth Grande arrived around 12:30 pm to talk with LPA's.

LPA Kontilas interviewed two staff at the facility regarding the death of the resident.
LPA De Leon requested the following records for Resident 1 (R1):
LIC. 602A Physicians Report, Appraisal Needs and Services Plan, Pre-Appraisal, Hospital /or Doctors records for visits or discharge, Staff notes, Centrally Stored Medication and Destruct Records, Medication Administration Records, Police Contact Information Case#/ Name/phone number, Enliven Sign in and out sheets for November, POA/Conservator records, Emergency Contact form, Enliven Resident Roster, Enliven Staff Roster with phone numbers, Enliven Staff Schedule for the week of November 21st-27th, Copy of Contract with Agency for staffing, Agency Contract Staff Schedule at Enliven for the week of November 21st-27th, List of Agency Contract staff names and phone numbers, Transfer associations for Agency Contract Staff.

The facility has a contract with an agency to provide additional care givers for residents at the facility. The same agency also has contracts with residents and their responsible parties for companionship. Staff 1 (S1) has a contract for care giving with the facility and also has contracts with residents at the facility for companionship. S1 does provide help with feeding for some residents and therefore must be associated to work at the facility due to the fact that S1 provides some type of care and is alone with residents in care at the facility.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MARAVILLA
FACILITY NUMBER: 425801937
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/30/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/30/2021
Section Cited

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(e) All individuals subject to a...
(1)...or
(2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or
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Based on record review the licensee did not comply with regualtion above and was working without a tranfer assocaition which poses an immediate risk to residents in care.
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Administrator will sign a statement that no staff will provide any care giving duties until associated to work at the facility. Facility will provide an up to date LIC 500 to LPA.

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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: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: MARAVILLA
FACILITY NUMBER: 425801937
VISIT DATE: 11/30/2021
NARRATIVE
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LPA De Leon referred the death of the resident to Community Care Licensing Investigation Branch (IB) for further investigation.

Exit interview conducted, deficiency cited, civil penalty assessed, copy of report and appeal rights emailed to Administrator.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3