585000698-5-6-2025-59-AS-KHOS-DGPSBV-20250515134434

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 585000698
Report Date: 05/06/2025
Date Signed: 05/06/2025 01:01:11 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/25/2025 and conducted by Evaluator Kerry Hiratsuka

COMPLAINT CONTROL NUMBER: 59-AS-20250225121819

FACILITY NAME:	MARBELLA MARYSVILLE		FACILITY NUMBER:	585000698
ADMINISTRATOR:	ROBERT COE		FACILITY TYPE:	740
ADDRESS:	515 HARRIS STREET		TELEPHONE:	(530) 749-1786
CITY:	MARYSVILLE	STATE: CA	ZIP CODE:	95901
CAPACITY:	72	CENSUS: 33	DATE:	05/06/2025
		UNANNOUNCED	TIME BEGAN:	11:10 AM
MET WITH:	Tracy Freudendahl		TIME COMPLETED:	01:10 PM

ALLEGATION(S):

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8
9

Staff do not keep resident's room cleaned

INVESTIGATION FINDINGS:

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12
13

Licensing Program Analyst conducted the investigation into the allegation above. LPA met with Executive Director Tracy Freudendahl.

LPA interviewed witnesses, staff, and residents. Based on the interviews the resident rooms are not cleaned thoroughly and some of the bathrooms were not cleaned at all.

Based on the information gathered through interviews, LPA was able to determine that the allegation is substantiated. Therefore, the Department finds the allegation to be Substantiated. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Please see 9099-D for the deficiency sited

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kerry Hiratsuka	TELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2025

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 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/25/2025 and conducted by Evaluator Kerry Hiratsuka

COMPLAINT CONTROL NUMBER: 59-AS-20250225121819

FACILITY NAME:	MARBELLA MARYSVILLE		FACILITY NUMBER:	585000698
ADMINISTRATOR:	ROBERT COE		FACILITY TYPE:	740
ADDRESS:	515 HARRIS STREET		TELEPHONE:	(530) 749-1786
CITY:	MARYSVILLE	STATE: CA	ZIP CODE:	95901
CAPACITY:	72	CENSUS:	DATE:	05/06/2025
		UNANNOUNCED	TIME BEGAN:	11:10 AM
MET WITH:	Tracy Freudendahl		TIME COMPLETED:	01:10 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff do not ensure that residents have clean laundry
Facility has insufficient staffing to meet resident needs

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst conducted the investigation into the allegation above. LPA met with Executive Director Tracy Freudendahl.

LPA interviewed witnesses, staff, and residents.

Based on the information gathered through interviews, LPA was unable to determine the laundry situation and the staffing. Some residents state they have no issues and some do but were unable to give specific information. The staffing issue LPA was uanble to determine because some residents don't have issues and some do. Based on the above LPA cannot prove or disprove because there are different version of events.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kerry Hiratsuka	TELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/25/2025 and conducted by Evaluator Kerry Hiratsuka

COMPLAINT CONTROL NUMBER: 59-AS-20250225121819

FACILITY NAME:	MARBELLA MARYSVILLE		FACILITY NUMBER:	585000698
ADMINISTRATOR:	ROBERT COE		FACILITY TYPE:	740
ADDRESS:	515 HARRIS STREET		TELEPHONE:	(530) 749-1786
CITY:	MARYSVILLE	STATE: CA	ZIP CODE:	95901
CAPACITY:	72	CENSUS:	DATE:	05/06/2025
		UNANNOUNCED	TIME BEGAN:	11:10 AM
MET WITH:	Tracy Freudendahl		TIME COMPLETED:	01:10 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff are not taking precautions to mitigate the spread of illness

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

LPA Hiratsuka conducted the investigation into the allegation above. LPA met with Executive Director Tracy Freudendah. Interviews indicate the staff member in question showed up to work in February 2025 without notifying anyone they were sick nor did they call anyone on the facility administration team to state they were sick. Another staff member called a manager and the manager then instructed the sick staff member to go home. The facility policy is to call whomever is in charge to let them know they are sick and not come in. The staff member indicated they would’ve come in sick and not call out. All staff have since been reminded of the staff policy for illness. Based on the staff member taking it upon themselves and not follow the facility policy the allegation is unfounded. No residents became ill due to the caregiver working.

Based on information above, the department concluded that the allegations are Unfounded. A finding that an allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

no deficiencies cited

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kerry Hiratsuka	TELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 4

Control Number 59-AS-20250225121819

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MARBELLA MARYSVILLE	FACILITY NUMBER: 585000698
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/06/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/06/2025 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	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.	1 2 3 4 5 6 7	By 06/06/2025, the licensee shall come up with a written plan of correction on how they shall ensure staff are held accountable on keeping rooms clean.
	8 9 10 11 12 13 14	This requirement not met as evidence by the facility based on interviews that stated the bathrooms were not cleaned and some of the rooms were not cleaned thoroughly, which poses a potential health and safety risk to resident 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: Troy Ordonez	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kerry Hiratsuka	TELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2025

LIC9099 (FAS) - (06/04)

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