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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 585000698
Report Date: 05/06/2025
Date Signed: 05/06/2025 12:58:50 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
04/14/2025 and conducted by Evaluator Kerry Hiratsuka
COMPLAINT CONTROL NUMBER: 59-AS-20250414150539
FACILITY NAME:MARBELLA MARYSVILLEFACILITY NUMBER:
585000698
ADMINISTRATOR:KRISTIE LAINEFACILITY TYPE:
740
ADDRESS:515 HARRIS STREETTELEPHONE:
(530) 749-1786
CITY:MARYSVILLESTATE: CAZIP CODE:
95901
CAPACITY:72CENSUS: 33DATE:
05/06/2025
UNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Tracy FreudendahlTIME COMPLETED:
01:10 PM
ALLEGATION(S):
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Medication(s) not given as prescribed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst conducted the investigation into the allegation above. LPA met with Executive Director Tracy Freudendahl.

The facility has had twelve medication errors in the past five weeks. One medication was present in the facility and staff didn't know it. The eleven was because a med tech called out and no one covered the shift. This is based on incident reports the facility submitted as required to Community Care Licensing Division. LPA cannot determine one incident if the resident suffered ill-effects was caused by the missed medication and the resident has since recovered. The other residents did not suffer any ill-effects. The facility staff did notify the doctors of the eleven residents about the missed medications.


Based on the above the allegation is substantiated.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (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 5
Control Number 59-AS-20250414150539
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: 05/06/2025
NARRATIVE
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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
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (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
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 59-AS-20250414150539
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 A
05/07/2025
Section Cited
CCR
87465(a)(5)
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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: Faciltiy staff, except those authorized by law
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By 05/07/2025, the licensee shall submit a written plan of correction on how they shall ensure there are staff to assist residents with medications and how they shall ensure that all medications are accounted for and distributed.
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shall not administer injections, but staff designated by the licensee may assist persons with self-administration as neededThis requirement not met as evidence by the facility based on record review of 11 medication errors which poses an immedaite health and safety risk to resident 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: Troy OrdonezTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (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)
Page: 3 of 5
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
04/14/2025 and conducted by Evaluator Kerry Hiratsuka
COMPLAINT CONTROL NUMBER: 59-AS-20250414150539

FACILITY NAME:MARBELLA MARYSVILLEFACILITY NUMBER:
585000698
ADMINISTRATOR:KRISTIE LAINEFACILITY TYPE:
740
ADDRESS:515 HARRIS STREETTELEPHONE:
(530) 749-1786
CITY:MARYSVILLESTATE: CAZIP CODE:
95901
CAPACITY:72CENSUS: 33DATE:
05/06/2025
UNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Tracy FreudendahlTIME COMPLETED:
01:10 PM
ALLEGATION(S):
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1. Facility staff not meeting hygiene needs of resident
2. Not enough staff to meet resident needs
3. Food not served at correctly.

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

1. LPA conducted the investigation into the allegation above. LPA reviewed the resident care plan. The device in question was not added to the resident’s care plan. The facility staff knew about the device and were instructed to clean it but it was not written down in the care plan. The staff did clean it but LPA cannot prove or disprove the times of day the device was cleaned because it was not written down in the care plan. The witness stated they had to clean it several times because it was not cleaned in the morning. The device has since been added to the care plan for the staff to clean it. The resident has not suffered any ill-effects. Because staff knew about cleaning the device but it was not written down LPA cannot prove or disprove the facility staff did not meet the hygiene needs of the resident because it was not written in the care plan.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (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 5
Control Number 59-AS-20250414150539
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: 05/06/2025
NARRATIVE
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2. & 3. LPA Hiratsuka interviewed residents and witnesses. Some stated the food comes at the correct temperature and some stated it doesn’t at times. Some stated the food is good and some stated the food was very hard to chew. Some stated there didn’t seem to be enough staff to serve the food and some stated everything is fine. LPA cannot prove or disprove because of the statements.

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
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (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
LIC9099 (FAS) - (06/04)
Page: 5 of 5