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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425801937
Report Date: 02/15/2023
Date Signed: 02/16/2023 12:36:38 PM

Substantiated


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
02/10/2023 and conducted by Evaluator Kristin Kontilis
COMPLAINT CONTROL NUMBER: 29-AS-20230210144006
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
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Ruth Grande, AdministratorTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Facility is in disrepair.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPAs) Mark Jeffries and Kristin Kontilis conducted an unannounced initial 10-day complaint investigation based on the above stated allegation. LPA met with Ruth Grande, Administrator and Luis Martinez, Maintenance Director and explained the purpose of the visit.
Entrance interview conducted:
LPAs conducted a physical tour of the facility to ensure health and safety precautions were met. At approximately 11:17 am, LPAs observed a sign posted on Elevator #1, located near the facility lobby in Assisted Living, stating the facility elevator is presently inoperable.
During the visit, LPAs obtained various documents pertinent to the investigation. From 11:25 am to 2:30 pm, LPAs conducted interviews with staff and residents in care. Interviews conducted revealed that Administrator and Maintenance Director are working closely with the elevator vendor to rectify the issue of the in-operable elevators.

Please continue to 9099-C, Pg 2.
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 29-AS-20230210144006
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: 02/15/2023
NARRATIVE
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 Interviews conducted revealed on 2/13/2023 Resident 1 (R1) was unable to return to R1’s room after a visit within the facility on a different floor. Interviews conducted revealed R1 was detained on the separate floor for approximately 2 hours.
Interviews conducted revealed on 2/11/2023 the two elevators in Assisted Living were not working properly.
During LPAs' visit, Administrator stated Elevator #1 was currently out of order and Elevator #2 was out of order on 2/11/2023, 2/13/2023, 2/14/2023, and is out of order on this day.
At the end of today's visit, Elevators #1 and #2 were repaired and working. However, through interviews conducted, it was discovered that the elevators were in need of modernization to avoid further repairs.
Pursuant to Title 22, Division 6, Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 9099-D):

Exit interview conducted. Copy of report issued and Appeal Rights 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
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20230210144006
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
02/22/2023
Section Cited
CCR
87303(a)
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87303(a) Maintenance and Operation: The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of Residents, employees and visitors.
This requirement is not met as evidenced by:
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Administrator agrees to develop a mobility plan for Residents on Floors 2 & 3 in the event the elevators are malfunctioning or broken. Administrator agrees to submit plan in place to LPA via email no later than POC due date.
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Based on interviews conducted, the licensee did not comply with the section cited above by Elevator 1 and Elevator 2 were not in working condition on 1/18/2023 and 2/10/2023; Elevator #2 was not working on 2/11/2023, 2/13/2023, and 2/14/2023. This posed a potential 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
LIC9099 (FAS) - (06/04)
Page: 3 of 3