425801937-12-30-2021-29-AS-KBUY-CA8QSH-20211231112535

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 425801937
Report Date: 12/30/2021
Date Signed: 12/30/2021 07:11:46 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/23/2020 and conducted by Evaluator Arien Diaz

COMPLAINT CONTROL NUMBER: 29-AS-20201223114835

FACILITY NAME:	MARAVILLA		FACILITY NUMBER:	425801937
ADMINISTRATOR:	GRANDE, RUTH E		FACILITY TYPE:	740
ADDRESS:	5486 CALLE REAL		TELEPHONE:	(805) 967-1965
CITY:	SANTA BARBARA	STATE: CA	ZIP CODE:	93111
CAPACITY:	131	CENSUS: 93	DATE:	12/30/2021
		UNANNOUNCED	TIME BEGAN:	04:35 PM
MET WITH:	Ruth Grande		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Facility illegally evicted resident
Staff did not provide adequate care and supervision to a Resident in care

INVESTIGATION FINDINGS:

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On 12/30/2021 at 4:48pm, Licensing Program Analyst (LPA) Diaz, conducted an unannounced complaint visit to issue final findings for the above allegations. LPA met with administrator Ruth Grande.

On 12/31/20 at 10:10 a.m., Licensing Program Analyst (LPA) Kristin Kontilis initiated a complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, the complaint investigation was conducted telephonically with Ruth Grande, Administrator. LPA Kontilis conducted a telephone interview with the Administrator and requested copies of documents pertaining to the investigation.

On 12/28/20 and 12/30/20, LPA Kontilis interviewed the complainant. On 07/21/21, LPA Lyndia Sager requested additional documents from the Administrator and at 3:40 p.m., conducted an interview with Witness #1 (W1).

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Arien Diaz	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20201223114835

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/30/2021

NARRATIVE

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On 08/02/21 at 4:35 p.m., LPA Sager conducted an interview with Administrator; on 08/03/21 from 1:22 p.m. to 4:45 pm., conducted interviews with Memory Care Director, Witness #2 (W2), and Witness #3 (W3); on 08/04/21 at 11:40 a.m., conducted an interview with Memory Care Charge Nurse.

On 12/01/20, Memory Care Resident #1 (R1) and Resident #2 (R2) were involved in a physical altercation where R1 bit the hand of R2. Paramedics were called and R1 and R2 were taken to the Goleta Valley Cottage Hospital Emergency Room for evaluation. R2 was treated for human bite wounds to both hands. The hospital refused to place R1 on a Psychiatric hold. R1’s Power of Attorney (POA) was called to pick up R1. Upon arrival back to the facility, the POA was informed he would need to provide a one-on-one caregiver for R1. The POA agreed that he would be the one-on-one caregiver for R1 and took R1 to the Independent Living apartment at Maravilla. The POA contacted the Primary Care Physician who recommended hospice placement. On 12/02/20, R1 was assessed and admitted to hospice with a recommendation for a 5-day respite for medication management of R1’s aggressive behavior. POA agreed as he was not able to continue to be a one-on-one caregiver for R1 as was needed due to the aggressive behaviors. Per the Administrator, the POA was informed of the need for a one-on-one caregiver, initially agreed to be the one-on-one caregiver, then refused and said he could not afford to pay for a one-on-one caregiver. R1 continued to stay with the POA until 12/04/20 when the POA moved R1 out of the facility.

R1 had previously lived in an Independent Living apartment at Maravilla with the POA. On 11/17/20, a pre-appraisal for R1 was completed by the POA and Memory Care Director, which did not indicate any aggression or behavioral issues. R1 transferred to the Memory Care unit of Maravilla on 11/17/20. Progress notes reviewed found that from 11/19/20 to 12/01/20, R1 had numerous incidents of increased confusion, wandering, agitation, yelling, medication refusal and aggressive behaviors. A Care Plan was completed on 11/17/20 noted that the resident had a current or history of behavior issues and needed hourly checks.

Information obtained through interviews found that the POA was notified that R1 would need a one-on-one caregiver and that the POA agreed and wanted to oversee R1. Other interviews found that the POA was under the impression they would be the one-on-one caregiver only overnight. W3 stated that the POA informed W3 that “R1 was asked to exit the memory care”. W3 stated R1 was initially placed on hospice on 12/02/20 for a 5-day respite for medication management in order to give the POA respite from the one-on-one caregiving.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Arien Diaz	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2021

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20201223114835

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/30/2021

NARRATIVE

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The respite was extended and R1 remains on hospice. Information obtained from the Administrator found that R1’s behavior could not be managed in the memory care without a one on one caregiver while medications were being adjusted. Administrator states R1 was not evicted, she did not issue an eviction notice due to on 12/03/20 the POA informed her that R1 would be moving out of the facility.

LPA Sager reviewed pertinent documents relevant to the allegations. LPA verified the one-on-one care clause in the Residence and Care Agreement which states: …”if it is determined that it is necessary to provide you with one-on-one care in order to protect your health and safety or the health and safety of others, we may provide or arrange for such care at our discretion and the charge for such one-on-one care, as set forth on Part C, Number 1, will apply immediately.”

Based on the information obtained during the course of the investigation, LPA Sager determined there is not a sufficient amount of evidence to support the above allegations. The above allegations are deemed Unsubstantiated.

Exit interview conducted and a copy of report given to Administrator.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Arien Diaz	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2021

LIC9099 (FAS) - (06/04)

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