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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 585000698
Report Date: 10/29/2025
Date Signed: 10/29/2025 03:52:02 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
10/06/2025 and conducted by Evaluator Kerry Hiratsuka
COMPLAINT CONTROL NUMBER: 59-AS-20251006085922
FACILITY NAME:MARBELLA MARYSVILLEFACILITY NUMBER:
585000698
ADMINISTRATOR:TRACY FREUDENDAHLFACILITY TYPE:
740
ADDRESS:515 HARRIS STREETTELEPHONE:
(530) 749-1786
CITY:MARYSVILLESTATE: CAZIP CODE:
95901
CAPACITY:72CENSUS: 43DATE:
10/29/2025
UNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Tracy FreudendahlTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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1. Staff who is not an appropriately skilled professional administered medication to resident
2. Staff did not keep accurate resident records
INVESTIGATION FINDINGS:
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Licensing Program Analyst conducted the investigation into the allegation above. LPA met with Executive Director Tracy Freudendahl.

LPA interviewed witnesses, staff, and residents. LPA also reviewed facility records.

1. Title 22 regulations does not allow staff to put medications directly into a resident's mouth. Interviews stated staff do put medications directly into residents' mouths. One med tech stated they always discuss medications with the residents and explains the processes and asks the residents if they want their medications put directly into the mouth. While this is a good idea the med tech is still not allowed to put the medication directly into a resident's mouth. Based on interviews, the allegation is substantiated.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2025
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
Control Number 59-AS-20251006085922
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
VISIT DATE: 10/29/2025
NARRATIVE
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2. One evening there was a resident who displayed symptoms of pain. The med tech stated they called hospice for direction and the hospice nurse gave directions for the medication. The resident spit the medication out and the med tech called hospice again and their manager to report what happened. Hospice gave directions for a second dose. The med tech didn't document the issue that occurred with the first dose in the facility's medication records. Based on the above, the allegation is substantiated.


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.

The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. appeal rights

Report reviewed with licensee . Copy of this report and appeal rights provided.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2025
LIC9099 (FAS) - (06/04)
Page: 2 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
10/06/2025 and conducted by Evaluator Kerry Hiratsuka
COMPLAINT CONTROL NUMBER: 59-AS-20251006085922

FACILITY NAME:MARBELLA MARYSVILLEFACILITY NUMBER:
585000698
ADMINISTRATOR:TRACY FREUDENDAHLFACILITY TYPE:
740
ADDRESS:515 HARRIS STREETTELEPHONE:
(530) 749-1786
CITY:MARYSVILLESTATE: CAZIP CODE:
95901
CAPACITY:72CENSUS: 43DATE:
10/29/2025
UNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Tracy FreudendahlTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff who is not an appropriately skilled professional administered manual fecal impaction removal to resident
INVESTIGATION FINDINGS:
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LPA Hiratsuka conducted the investigation into the allegation above. LPA met with Executive Director Tracy Freudendah.

LPA interviewed the resident in question and staff. The incident did not occur.

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.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2025
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-20251006085922
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: 10/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/30/2025
Section Cited
CCR
87465(a)(4)
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Incidental Medical and Dental Care. A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:The licensee shall assist residents with
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By 10/30/2025, the licensee shall come up with a written plan of correction on how they shall ensure staff do not put any medications directly into a resident's mouth.
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self-administered medications as needed. This requirement not met as evidence by the facility based on interviews with indicate staff put medications direclty into a resident's mouth which poses an immedaite health and safety risk to resident in care.
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Type B
11/28/2025
Section Cited
CCR
87465(c)(3)
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Incidental Medical and Dental Care.If the resident's physician has stated in writing that the resident is unable to determine his/her ... nonprescription PRN medication but can communicate his/her symptoms cleary, facility staff designated by the licensee shall be permitted to assist the.. self-administration,
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By 11/28/2025, the licensee shall come up with a written plan of correction how they shall ensure staff document response's to medications given to them with it is a PRN.
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provided all of the following requirements are met:A record...maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response. Staff forgot to document resident's response to a medication given.
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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.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4