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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425801937
Report Date: 02/24/2022
Date Signed: 02/24/2022 04:57:15 PM


Document Has Been Signed on 02/24/2022 04:57 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:MARAVILLAFACILITY NUMBER:
425801937
ADMINISTRATOR:GRANDE, RUTH EFACILITY TYPE:
740
ADDRESS:5486 CALLE REALTELEPHONE:
(805) 967-1965
CITY:SANTA BARBARASTATE: CAZIP CODE:
93111
CAPACITY:131CENSUS: 93DATE:
02/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Ruth Grande and Mariana PelayoTIME COMPLETED:
05:05 PM
NARRATIVE
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On 02/24/22 at 10:30 a.m., Licensing Program Analyst (LPA) Toan Luong conducted an unannounced One Year Infection Control Annual visit to the facility. LPA met with Administrator Ruth Grande and Regional Nurse Mariana Pelayo and explained the purpose of the visit.

LPA was screened at the entrance, and LPA toured the residential care facility for the elderly. At 12:00 p.m., LPA discussed items in the Infection Control Module and noted that facility answered yes to all questions in the Infection Control. Infection Control module was addressed with administrator to satisfaction. Between 12:30 p.m. and 2:00 p.m., LPA reviewed facility schedule and found 2 individual working at the facility without a Criminal Record Clearance. Individuals were not present at the facility during the inspection. Administrator removed staff from the schedule until they receive clearance. LPA issued citation under Title 22, Division 6 Chapter 8 Article 06. Background Check 87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department. At 10:47 a.m., LPA and administrator entered the Memory Care Unit and found a unlocked cabinet in room near the memory care entrance. Caregivers were not present in the area and one resident was observed in the room. Cabinet contained 3 cleaning spray bottles with the label Peroxide Multi Surface Cleaner and 1 bottle of Joy dishwasher soap. Staff locked the cabinet. LPA issued citation under Title 22, Division 6 Chapter 8 Article 12. Dementia 87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia:(2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

Deficiency issued on LIC 809D. A civil penalty was issued. LPA conducted exit interview with administrator and emailed a copy of today's report and appeal rights to the administrator.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Toan LuongTELEPHONE: (626) 419-1827
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2022
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 02/24/2022 04:57 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: 02/24/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(1)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, LPA reviewed Guardian Roster and found 2 individuals on the facility schedule without a Criminal Record Clearance. The licensee did not comply with the section cited above in 2 counts which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/24/2022
Plan of Correction
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Administrator removed staff from schedule. Administrator agreed to verify hired staff is on CDSS personnel roster aka Guardian before allowing staff to work at the facility
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, LPA and administrator observed cleaning product in an unlocked cabinet in the Memory Care Unit. The licensee did not comply with the section cited above in 4 counts which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/24/2022
Plan of Correction
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Staff locked cabinet. Administrator will hold inservice and submit proof to LPA by 2/24/22.

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: Toan LuongTELEPHONE: (626) 419-1827
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2022
LIC809 (FAS) - (06/04)
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