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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425801937
Report Date: 02/15/2023
Date Signed: 02/15/2023 02:46:29 PM


Document Has Been Signed on 02/15/2023 02:46 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: 115DATE:
02/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Ruth Grande, AdministratorTIME COMPLETED:
03:30 PM
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Licensing Program Analysts (LPAs) Mark Jeffries and Kristin Kontilis conducted an unannounced on-site one-year Infection Control Inspection visit to the above-named facility. LPAs arrived at 10:35 am and was greeted by Staff 1 (S1). LPAs explained the purpose of the visit. Ruth Grande, Administrator participated in the inspection at approximately 11:10 am. Also participating in the inspection visit were Luis Martinez, Maintenance Director and Mariana Pelayo, Regional Nurse.
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 15 residents with a dementia diagnosis, 17 residents on hospice, and 7 bedridden residents.
A tour of the physical environment and accommodations were assessed, and the following was noted: LPAs observed the required posting of the complaint poster, bill of rights and Resident’s Rights. LPAs inspected the facility for fire safety, personal accommodations, and food service.
The physical environment was checked for cleanliness and condition. Walls, windows, ceilings, doors, floors and floor coverings were checked.
There are two kitchens where food is prepared. Each kitchen is equipped with industrial kitchen equipment and is kept neat and clean. The facility maintains a comfortable temperature.
Medications, First Aid kit, and additional first aid supplies are kept in the locked Nurse’s station. In a separate locked room within the Nurse’s station, multiple rolling medication carts are also secured. Additionally, residents’ records are kept in the locked Nurse’s station. Additional First Aid kits are stored in various areas throughout the facility including but not limited to the kitchen areas, Memory Care medication room, Administration area, Maintenance Department, and the Housekeeping Department.
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, and other local attractions. Please continue to 809-C, Pg 2.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
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
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 If any suspected or confirmed cases of COVID-19 are found in the facility a staff will be assigned to only work with those quarantined/isolated individuals and will not work with other COVID-19 negative individuals until cleared by Health Department. Staff will use full PPE with N95 masks and face shields when dealing with any pending or confirmed cases of COVID-19. Precautionary Droplet signs will be posted on any room with quarantine or isolated individuals.
PPE supplies will be located immediately outside those rooms when required. Facility has a 30-day supply of PPE on hand. Facility has plans for delivering medications and meals to any quarantined/isolation resident room.
The facility has proper cleaning and disinfectant sprays. Facility Administrator has a plan in place for when and whom to notify in an outbreak or other emergencies. Administrator will keep a line list of all vaccinated and tested staff/residents in care with dates/results.
Facility has conducted training on infection prevention, symptoms, transmission and PPE use. Facility has non-punitive sick leave polices for staff. Staff who have a respiratory illness are requested to stay home and not report to work.
Activities have been modified to individuals or small groups with social distancing. Residents' medication is delivered in 30-day supplies to the facility. The facility ensures proper cleaning is done on frequently touched surfaces and between any individuals sharing of space or items.
Sinks were well stocked with soap, paper towels and hand washing signs. Staff and resident records are kept in the locked staff office. Facility observes guidance changes and the most up-to-date guidance from CCL-PINS, CDC, CDPH, and local health departments should be followed to remain in compliance. The most stringent orders should be followed by any of these agencies.

Exit interview conducted. Facility is following Infection Control protocols. Copy of report issued at the time of the visit.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
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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