425801937-2-8-2024-29-AS-KKOS-D2955Z-20240207183958

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425801937
Report Date: 02/07/2024
Date Signed: 02/08/2024 02:36:46 PM

Document Has Been Signed on 02/08/2024 02:36 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

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: 107	DATE:	02/07/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:05 PM
MET WITH:	Ruth Grande, Administrator		TIME COMPLETED:	05:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced Annual Inspection to the above-named facility. LPA was greeted by Staff 1 (S1) and explained the purpose of the visit. Ruth Grande, Administrator participated in the inspection at approximately 12:55 pm. Entrance interview conducted. The facility is a three-story Residential Care Facility for the Elderly (RCFE) with a hospice waiver for 20. Currently, there are 20 residents with a dementia diagnosis, 18 residents on hospice, 10 residents on oxygen, and 3 bedridden residents. A tour of the physical environment and accommodations were assessed, and the following was noted: LPA observed the required posting of the complaint poster, bill of rights and Resident’s Rights. LPA inspected the facility for fire safety and other hazards. The facility entrance consists of a large lobby, a concierge desk for check-in, and a hallway at the right of the lobby leading to the administration offices. Immediately past the concierge’s desk is a stairway that leads to the residential area. Residents participate independently in live entertainment and music, worship support, exercise activities, card games, lectures, Resident Council Townhall meetings, Bingo, art, reading club, pet therapy, arts and crafts, and outings to parks, restaurants, shopping excursions, museums, theatre events, and other local attractions. The fire extinguishers were charged and last serviced on 12/28/2023. LPA observed elevators are in good working order. Please continue to 809-C, Page 2.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2024

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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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: 02/07/2024

NARRATIVE

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During today’s visit, the medication inventory and Medication Administration Record (MAR) for Resident 1 (R1) revealed an overcount of Metropolol XL 100mg. R1’s prescribed medication of Metropolol XL 100mg medication began on 10/31/2023 with a bottle count of 150 tablets. R1’s prescribed medication is 1x per day in the AM administered from 10/31/2023 through 2/7/2024. At approximately 2:46 pm, Staff 1 (S1) conducted a medication count and determined there were 125 tablets remaining in the bottle. At approximately 2:55 pm, Staff 2 (S2) confirmed a medication count of 125 tablets remaining in the bottle. At approximately 3:12 pm, Staff 3 (S3) also confirmed a medication count of 125 tablets remaining in the bottle. S3 stated there is no record of R1 refusing medications from 10/31/2023 through 2/7/2024 and the MAR reflects the am medication was given in the am from 10/31/2023 to 2/7/2024.

Due to time restraints, LPA will return at a later date to continue the annual inspection.

The following deficiencies were observed (see LIC 809-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/08/2024 02:36 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MARAVILLA	FACILITY NUMBER: 425801937
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(c)(2)

87465(c)(2) Incidental Medical and Dental Care: Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interviews conducted, and record review, the licensee did not comply with the section cited above when it was determined that there was an unexplainable overcount of R1's medication which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/09/2024
	Plan of Correction
1 2 3 4	Adminsitrator agrees to conduct an in-service with all staff who administer medications (Med Aides and Licensed Nurses) on the protocol of properly recording administration of medications, counting medications, and ensuring medications adminstered and medications remaining are accurate. Administrator agrees to provide written documentation of in-service training including first and last names of attendees, date and description of in-service. Administrator agrees to send proof of training to LPA via email no later than 2/9/2024.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2024

LIC809 (FAS) - (06/04)

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