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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425801937
Report Date: 02/15/2023
Date Signed: 10/10/2023 09:21:26 AM


Document Has Been Signed on 10/10/2023 09:21 AM - It Cannot Be Edited

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: 115DATE:
02/15/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Ruth Grande, AdministratorTIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Mark Jeffries and Kristin Kontilis conducted a Case Management visit to address deficiencies noted during Complaint Control #29-AS-20230210144006 investigation visit conducted on 2/15/2023. LPAs met with Ruth Grande, Administrator and explained the purpose of the visit.

On 2/14/2023, CCL received notification that Resident 1 (R1) was placed on hospice on 2/4/2023. Hospice notification states, “I apologize this is late”.

On 2/14/2023, CCL received notification that on 2/3/2023, 9-1-1 was called for Resident 2 (R2) when Staff 1 (S1) observed R1 had a cough, congestion, and with white foam at the mouth.



Pursuant to Title 22, Division 6, Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D)
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2023
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 10/10/2023 09:21 AM - 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: MARAVILLA
FACILITY NUMBER: 425801937

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/22/2023
Section Cited
CCR
87632(d)(2)

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87632(d)(2) Hospice Waiver: The licensee shall notify the Department in writing within five working days of the initiation of hospice care services for any terminally ill resident in the facility or within five working days of admitting a resident already receiving hospice care services.
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Administrator agrees to conduct training with all directors and nurses of timing required for hospice notification. Training records will show full names of attendees, date of training, and person conducting training.
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Based on records review, the licensee did not comply with the section cited above when staff did not notify R1’s hospice placement within five working days from date of placement which poses a potential health and safety risk to residents in care.
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Type B
02/22/2023
Section Cited
CCR87211(a)(1)

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87211(a)(1) Reporting Requirements: A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below…
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Administrator agrees to conduct training with all directors, nurses of reporting requirements. Training records will show full names of attendees, date of training, and person conducting training.
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Based on records review, the licensee did not comply with the section cited above when staff did not submit a Serious Illness/Serious Injury report for R2’s change of condition within seven days of the occurrence which poses a potential health and safety risk to residents in care.
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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: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2023
LIC809 (FAS) - (06/04)
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