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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425801937
Report Date: 02/15/2023
Date Signed: 02/16/2023 10:51:24 AM


Document Has Been Signed on 02/16/2023 10:51 AM - 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:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Ruth Grande, AdministratorTIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Mark Jeffries and Kristin Kontilis conducted an unannounced Case Management – Incident visit to the facility today. LPA met with Ruth Grande, Administrator and explained the purpose of the visit. The purpose of today’s visit is to address a self-reported incident reported to CCL on 1/19/2023.

Staff 1 (S1) reported Resident 1 (R1) is prescribed Seroquel (25 mg) each morning at 9:00 am.

Incident report states S1 was contacted by R1’s POA to let S1 know that R1 had not been administered the medication on 1/13/2023 due to the “medication not being on hand”. S1 reviewed R1's MAR and discovered the medication had not been administered on 1/13/2023, 1/14/2023, and 1/15/2023 and discovered the medication was in the overflow cart.

Incident report states a retraining will be done with Staff 2 (S2) and Staff 3 (S3) to follow medication protocol to conduct a thorough search of medication cart rather than assume medications are not available along with re-training licensed nurses and care directors to monitor electronic MAR dashboard for missed medications. Incident report further states Administrator will submit training information to CCL/LPA no later than 1/25/2023. Records reviewed revealed CCL/LPA did not and has not received training information regarding incident.

Pursuant to Title 22, Division 6, Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D):

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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Document Has Been Signed on 02/16/2023 10:51 AM - 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
02/17/2023
Section Cited

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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:
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Administrator agrees to conduct medication training with all staff and provide training records with full name, signatures, dates, and description of training to CCL by 2/17/2023.
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Based on records review, the licensee did not comply with the section cited above when staff did not follow physician’s orders for medications, which posed an immediate health and safety risk to residents in care.
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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: Kristin KontilisTELEPHONE: (805) 689-2787
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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