425801937-3-4-2022-29-AS-KBUY-CC7VUQ-20220304154507

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 425801937
Report Date: 03/04/2022
Date Signed: 03/04/2022 12:51:22 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
03/09/2020 and conducted by Evaluator Toan Luong

COMPLAINT CONTROL NUMBER: 29-AS-20200309125214

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: 90	DATE:	03/04/2022
		UNANNOUNCED	TIME BEGAN:	12:25 PM
MET WITH:	Ruth Grande		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Staff did not communicate changes in resident's functionality to the resident's authorized representative and physician.
Staff do not follow resident's care plan properly.
Staff do not respond to resident's call button in a timely manner.
Staff is unable to communicate to resident due to a language barrier.
Residents' needs are not being met due to facility being understaffed.

INVESTIGATION FINDINGS:

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On 3/4/22 at 12:25 p.m., Licensing Program Analyst (LPA) Toan Luong conducted a subsequent complaint visit to deliver findings for the above allegations. LPA met with Administrator Ruth Grande and explained the reason for the visit.

On 03/19/2020, at 1:43pm, Licensing Program Analyst (LPA) Kristin Kontilis initiated a complaint investigation for the allegations listed above. At approximately 2:09pm, LPA Kontilis conducted a telephone interview with the Administrator and requested copies of documents pertaining to the investigation. On 12/22/2021, from 3:30pm to 4:30pm, and on 02/11/2022, from 11:00am to 5:20pm, LPA Kontilis conducted subsequent complaint visits to the facility to continue the investigation and obtain additional pertinent documents. LPA Kontilis interviewed Administrator, staff and residents on 02/11/2022 from 11:35am to 3:45pm. On 02/24/2022, from 1:35pm to 4:21pm, LPA Toan Luong, conducted additional resident and staff interviews. On 03/01/2022, from 2:17pm to 2:36pm, LPA Lyndia Sager interviewed former Assisted Living Director, Christine Cortez.
(Continued on 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Toan Luong	TELEPHONE: (626) 419-1827
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2022

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 3

Control Number 29-AS-20200309125214

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: 03/04/2022

NARRATIVE

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Resident #1 (R1) physician report, dated 09/16/2019, lists the primary diagnosis as stroke, Bradycardia, and Dementia. On 09/17/2019, (R1) was admitted to the memory care portion of the facility. After three (3) weeks, R1’s condition improved and R1 was transferred to a private apartment in the Assisted Living portion of the facility at the request of R1’s Representative. Based on the 10/04/2019 Health and Service Evaluation, R1 did not have any wandering, disruptive, aggressive or inappropriate behavior and R1 required minimal to no assistance with transferring, showering, grooming, dressing, toileting, and meal consumption. R1 required status checks four (4) times per shift, required a one (1) person total assist or wheelchair escort to and from activities and meals, and required stand-by assistance three (3) times per week with bathing. R1 also used a wander guard alert device.

On the allegation: Staff did not communicate changes in resident's functionality to the resident's authorized representative and physician. Health and Services Evaluations and Service Plans, dated 10/04/2019, 11/01/2019 and 01/23/2020 were reviewed for (R1). Each of the plans were signed and dated by the facility LVN and R1’s Representative. LPA Sager reviewed Nursing Progress Notes dated 09/17/2019 through 03/13/2020. The notes reflect that R1’s Representative was notified in person and by phone with updates on a frequent basis regarding R1. R1’s physician was also notified by phone when R1 had a change of condition. Based on the information obtained, the allegation is deemed unsubstantiated at this time.

On the allegation: Staff do not follow resident's care plan properly. R1’s care plan (service plan) reflected that R1 required status checks four (4) times each shift when family or private caregiver was not present. Based on information obtained through interviews, staff performed status checks as noted in service plan; however, during the overnight shift, R1 did not like staff coming into the apartment when R1 was sleeping. R1 did not like to be awakened in the middle of the night. R1’s Representative requested that R1 not be checked on during the night as R1 was a light sleeper. R1’s Representative was advised that R1’s service plan needed to be followed with staff performing the status checks for the health and safety of R1. R1’s service plan also indicated R1 required standby assistance with showers three (3) times per week. R1 needed to be prompted to take showers and sometimes would refuse. Per the Administrator, R1’s Representative was made aware that R1 sometimes refused showers. Staff interviews revealed that they are made aware of resident service plans. Staff stated they document in the summary log if they observe changes and notify the nurse. The nurse will give updates at the beginning of each shift if there are any resident change of condition or a new resident service plan to follow. Based on the information obtained, the allegation is deemed unsubstantiated at this time. (Continued 9099C)

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Toan Luong	TELEPHONE: (626) 419-1827
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 29-AS-20200309125214

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: 03/04/2022

NARRATIVE

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On the allegation: Staff do not respond to resident's call button in a timely manner. LPA Sager was unable to obtain a copy of the call button response time logs for the time period of November 2019 through March 2020 as the facility does not keep records of call logs for more than the current year. Information obtained through resident interviews revealed that more often than not, the call button response time is adequate. Per the Administrator, the expectation is that staff respond within 10 minutes or less. If no response after 10 minutes, then another alert will notify upper management. Staff interviewed stated the response time to the call button was 7 to 10 minutes. Based on the information obtained, the allegation is deemed unsubstantiated at this time.

On the allegation. Staff is unable to communicate to resident due to a language barrier. Resident interviews revealed that they are able to communicate with staff and that all of the direct care staff speak English. Per the Administrator, one of the requirements upon being hired as a direct care staff is that you must be able to speak English. Other facility staff (cooks, dishwashers, housekeepers) are not required to speak fluent English. Based on the information obtained, the allegation is deemed unsubstantiated at this time.

On the allegation: Residents' needs are not being met due to facility being understaffed. LPA Sager reviewed staff schedules for December 2019 through March 2020. There are five (5) to six (6) direct care staff, two (2) med aides, and one (1) nurse on the A.M. shift; four (4) to five (5) direct care staff, two (2) med aides, one (1) nurse on the P.M. shift; and two (2) direct care staff, one (1) med aide on the NOC (overnight) shift. Based on information obtained through Administrator and former Assisted Living Director interviews, there was a sufficient amount of staff to meet the residents’ needs as majority of the residents in assisted living required minimal care and assistance. R1 had a private duty caregiver (companion) during the day four (4) days per week. Staff interviewed stated they believed the staffing was sufficient for the residents’ needs. Based on the information obtained, the allegation is deemed unsubstantiated at this time.

Exit interview conducted and a copy of this report and appeal rights emailed to administrator.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Toan Luong	TELEPHONE: (626) 419-1827
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2022

LIC9099 (FAS) - (06/04)

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