425801937-2-15-2023-29-AS-MJES-CP3URC-20230215144830

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425801937
Report Date: 02/15/2023
Date Signed: 02/15/2023 02:52:38 PM

Document Has Been Signed on 02/15/2023 02:52 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: 115	DATE:	02/15/2023
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Ruth Grande / Adminsitrator		TIME COMPLETED:	03:30 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 Analysts (LPA's) Mark Jeffries and Kristin Kontilis, conducted a Case Management - Deficiencies visit to issue final findings and citations related to the Case Management visit conducted on 11/30/2021. LPA Jeffries and Kontilis met with Administrator, Ruth Grande. On 11/30/2021, from 9:40am to 3:20pm, Licensing Program Analysts (LPAs) Rachael De Leon and Kristin Kontilis conducted a case management visit to the facility regarding an email from the Administrator reporting the death of Resident #1 (R1) on 11/26/2021. LPAs De Leon and Kontilis met with Staff Christina Martinez, Director of Enliven Memory Care and explained the purpose of the visit. Administrator Ruth Grande arrived at approximately 12:30 pm to meet with the LPAs. The LPAs conducted staff interviews and obtained copies of documents pertinent to the investigation. The LPAs determined further investigation was needed. The case was referred to the CCL Investigations Branch (IB) and assigned to Investigator Robert Kujawa. Investigator Kujawa conducted interviews on 12/03/2021, at approximately 10:12am, with the Administrator; on 12/27/2021, from approximately 3:38pm to 4:58pm, with staff; on 06/23/2022, at approximately 1:58pm, with Staff #1 (S1); and on 07/14/2022, at approximately 1:00pm, with the Memory Care Director. In addition, Investigator Kujawa reviewed facility file documents related to R1, video footage of the facility dated 11/24/2021, and the Santa Barbara County Coroner’s Report. On 10/26/2021, R1 was admitted to the Enliven Memory Care portion of the facility. The admission assessment noted R1 had a diagnosis of dementia, hypertension, confusion, depression, no cognitive disease, and no suicidal/self-abuse behaviors. CONTINUED on LIC809-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark Jeffries	TELEPHONE: (805)562-0400
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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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: 02/15/2023

NARRATIVE

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On 11/24/2021, R1 went on an outing with a private caregiver (S1). R1 asked S1 to buy R1 some antifreeze, and S1 purchased the antifreeze. The video footage of the facility’s lobby dated 11/24/2021 at 11:55am showed R1 and S1 walking into the lobby together, with S1 holding the bottle of antifreeze. At 01:33 of the video, it shows S1 holding the antifreeze in his right hand and looking toward a facility staff member’s direction. At 01:34 of the video, it shows S1 motioning his left hand and tapping the bottle of antifreeze. On 11/26/2021, R1 was found deceased in R1’s bedroom and a bottle of open antifreeze was found under R1’s pillow.

When interviewed, S1 admitted to working in the memory care field for many years. S1 stated they bought the antifreeze because R1 would not stop asking for something from the auto parts store, and then requested antifreeze once they arrived at the store. S1 stated they took the antifreeze into the facility to appease R1. S1 stated they notified two staff in the facility about the antifreeze so they would immediately remove it. However, one of the staff mentioned was later interviewed and refuted this claim, denying that they were ever told about the antifreeze; the other staff was unable to be interviewed.

Interviews conducted with facility staff revealed that at least one staff observed the bottle of antifreeze in R1’s closet, and the staff tried to remove it from R1’s room but R1 yelled at the staff to get out of R1’s room. The staff stated they did not inform management about the bottle but did tell a couple of coworkers. One other staff stated they searched for the bottle in R1’s room, after the other staff informed them of the bottle, but they did not see it. Multiple facility staff members had knowledge R1 had the antifreeze bottle in R1’s room and did not notify facility management or remove the antifreeze before R1 ingested it. R1 had no vehicle to have a need for antifreeze in their possession, nor any viable reason, and had a diagnosis of dementia and should not have had access to the antifreeze. The Santa Barbara County Coroner ‘s office determined R1’s cause of death was a result of Ethylene Glycol Ingestion with the manner of death being suicide.

CONTINUED on LIC809-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark Jeffries	TELEPHONE: (805)562-0400
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

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: 02/15/2023

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Based on the information obtained throughout the course of the investigation, there is sufficient evidence to support the allegation of Questionable Death, therefore the allegation is deemed Substantiated at this time.

A $500 immediate civil penalty is assessed today. The Administrator, Ruth Grande was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e).

Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 809-D).

Exit interview conducted, appeal rights provided, a copy of this report issued.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark Jeffries	TELEPHONE: (805)562-0400
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

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/15/2023 02:52 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: 02/15/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/16/2023 Section Cited	1 2 3 4 5 6 7	Care of Persons with Dementia (f)The following shall be stored inaccessible to residents with dementia: (2)Over-the-counter medication,..., and toxic substances ...,cleaning supplies and disinfectants. This requirement is not met as evidenced by: Based on interviews and record review,	1 2 3 4 5 6 7	Licensee to submit plan how you will ensure all toxics will be stored inaccessible to residents in care. Submit to CCL by 2/16/2023.
	8 9 10 11 12 13 14	the licensee did not comply with the above section by failing to remove and secure R1’s antifreeze, thus allowing R1 to ingest the antifreeze causing death, which posed an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Mark Jeffries	TELEPHONE: (805)562-0400
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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