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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425801937
Report Date: 06/07/2024
Date Signed: 06/07/2024 11:32:28 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
01/10/2024 and conducted by Evaluator Erika Miller
COMPLAINT CONTROL NUMBER: 29-AS-20240110084949
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: 111DATE:
06/07/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Ruth GrandeTIME COMPLETED:
11:45 PM
ALLEGATION(S):
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Staff did not assist resident to the correct room.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Erika Miller (Miller) conducted an unannounced complaint visit on January 16, 2024. On June 7, 2024. LPA issued final findings on the allegations above. During the investigation, LPA Miller, toured the facility and interviewed staff on January 16, 2024, from 1:00 p.m. to 3:00 p.m. LPA also obtained and reviewed relevant documents. LPA met with Ruth Grande, administrator and explained the purpose of the visit.

On the allegation: Staff did not assist resident to the correct room. It was alleged that caregivers mixed up two male residents in the memory care unit (Resident 1 and Resident 2). LPA interviewed R1’s visitor, who stated on January 6, 2024 they visited the facility and asked staff where R1 was. Staff replied R1 was in their room being changed. When the visitor arrived at R1’s room, visitor saw R2 being changed in R1’s room. Visitor stated they found R1 across the hall in R2’s room, sleeping.
(Cont.on 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Erika MillerTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2024
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 5
Control Number 29-AS-20240110084949
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: MARAVILLA
FACILITY NUMBER: 425801937
VISIT DATE: 06/07/2024
NARRATIVE
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Interviews determined the staff who mixed up R1 and R2 was from a caregiver agency. Staff interviewed stated sometimes agency staff are not reminded to look in resident binders to confirm who the resident is. LPA reviewed residents’ Service Plan, which stated Resident 1 (R1) requires two-person total assistance for transferring, dressing, and toileting. Staff interviewed stated the agency staff failed to follow policy by disregarding the transferring policy of R1. Agency staff toileted, dressed and transferred R1 without assistance and resulted in R1 being returned to wrong room and bed. Staff stated the agency staff worked on their own and did not collaborate with the other facility staff, and had a bad attitude about the incident. Following the incident, facility management decided this agency staff would not work in memory care and later not in the facility at all. Neither staff nor Administrator denied that the incident took place.

Based on the information obtained, the allegation is deemed Substantiated at this time.

Exit interview, deficiencies cited 9099-D, report given, appeal rights given.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Erika MillerTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20240110084949
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MARAVILLA
FACILITY NUMBER: 425801937
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/07/2024
Section Cited
CCR
87468.2(a)(4)
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Additional Personal Rights of Residents...(a)Residents shall have rights...(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in competency to meet their needs. This requirement is not met as evidenced by:
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Agency staff involved in the incident was asked to not return to the facility. Administrator reminded other staff to follow policies and care plans for all residents on 1/9/24 and 2/23/24.
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Based on interviews, the licensee did not comply with this section when staff lacked competency in mixing up R1 & R2, which posed 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: Erika MillerTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
01/10/2024 and conducted by Evaluator Erika Miller
COMPLAINT CONTROL NUMBER: 29-AS-20240110084949

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: DATE:
06/07/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:TIME COMPLETED:
11:45 PM
ALLEGATION(S):
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Facility does not have adequate staff to meet the needs of residents.
INVESTIGATION FINDINGS:
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On the allegation: Facility does not have adequate staff to meet the needs of residents. It was alleged the facility did not have enough staff, which led to the mix up of R1 and R2.

Staff interviewed stated 2 caregivers on duty was not enough due to the high needs of residents. Staff stated it would be helpful if there was a third caregiver, especially for when staff go on break. Staff stated sometimes they try to call the nurse for assistance but they are not always available. Staff interviewed stated they were supposed to have 3 caregivers but allegedly had only 2 due to budget cuts. Staff stated with only 2 staff working, they have to do everything in a hurry. Staff stated sometimes residents do not get showers on the day they were scheduled for, but they try again on the next shift.

Administrator stated they have 2 caregivers and one med tech. Administrator stated they have another med tech in the whole building and a nurse, as well as the memory care director and activities director.
Continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Erika MillerTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20240110084949
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: MARAVILLA
FACILITY NUMBER: 425801937
VISIT DATE: 06/07/2024
NARRATIVE
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Documents provided indicated in January 2024, the facility had 16 residents in the memory care, 8 of which required two-person assist. During January 2024, scheduled indicated there were two caregivers and one med tech. Effective February 2024, three caregivers and one med tech were assigned.

Although, the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Technical Assistance is issued to remind the facility they should adjust their staffing ratio appropriately based on resident’s needs.

Exit interview conducted, copy of report issued.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Erika MillerTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5