045000603-3-13-2025-59-AS-RKNT-DEQRYA-20250313132602

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 045000603
Report Date: 03/13/2025
Date Signed: 03/13/2025 01:27:00 PM

Document Has Been Signed on 03/13/2025 01:27 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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

FACILITY NAME:	MARBELLA OROVILLE		FACILITY NUMBER:	045000603
ADMINISTRATOR/ DIRECTOR:	LAINE, KRISTIE		FACILITY TYPE:	740
ADDRESS:	400 EXECUTIVE PARKWAY		TELEPHONE:	(530) 534-8160
CITY:	OROVILLE	STATE: CA	ZIP CODE:	95966
CAPACITY: 88		CENSUS: 44	DATE:	03/13/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:45 AM
MET WITH:	April Kale - Executive Director in training		TIME VISIT/ INSPECTION COMPLETED:	01:30 PM

NARRATIVE

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03/13/2025 09:45 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with Executive Director in training April Kale and Jaluisa Tippens Resident Care Director and explained the purpose of the visit.

LPA Knight and the Executive Director in training toured the facility together to ensure the health and safety of residents in care. Areas toured include but are not limited to resident apartments, bathrooms, common areas, kitchen, laundry rooms, activity area, and yard. LPA toured both floors of the assisted living section of the facility and the lower floor memory care unit. Staff and resident files were reviewed. All employees requiring background checks are cleared. Facility has a hospice waiver for 10 residents. Medication is locked in a secured medication room. Medications were reviewed.

The facility was observed to be at a comfortable temperature. Hot water measured between 105 – 120 degrees F. Common area was clean and in good repair. All inspected rooms had required furniture, bedding, and lighting. Bathrooms were clean and in good repair. Kitchen was clean and in good repair. Food appears to be stored and prepared properly. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food. Fire extinguishers fully charged and inspected. Smoke detectors are all operational, hard wired to the fire department and tested annually by Johnson Controls. There are no pools/bodies of water are on premises. Last disaster drill was conducted in May 2025, which was an elopement drill, the facility has been conducting fire drills quarterly for each shift.

Continued on LIC809-C

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 OROVILLE	FACILITY NUMBER: 045000603
	VISIT DATE: 03/13/2025

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There is a schedule of recreational activities planned for the residents and residents participate in the activities of their choice. During the inspection LPA observed residents participating in activities with the activities director. During the visit LPA observed a community choir performing in the memory care unit and assisted living portions of the facility.

LPA requested the following documents that need to be updated in the facility file:

LIC500 Personnel Report

The following deficiencies were observed during the inspection:

During tour of the facility LPA observed laundry detergent accessible to residents in 2 of 2 assisted living laundry rooms.

During staff files reviews LPA observed that first aid training expired for 4 of 6 staff files. 1 of 6 staff files did not include first aid training.

Deficiencies are being cited as a result of today’s inspection in accordance with California Code of Regulations, (Title 22) and are documented on the attached LIC809-D

Exit interview conducted and copy of report and appeal rights were provided to Executive Director in training April Kale.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/13/2025 01:27 PM - It Cannot Be Edited

Created By: Rebecca Knight On 03/13/2025 at 12:51 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: MARBELLA OROVILLE	FACILITY NUMBER: 045000603
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87309(a)

Storage Space and Access

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation the licensee did not comply with the section cited above in 2 of 2 laundry rooms which poses a potential health, safety or personal rights risk to persons in care. LPA observed laundry detergent accessible to residents in 2 of 2 assisted living laundry rooms.
	POC Due Date: 03/27/2025
	Plan of Correction
1 2 3 4	Licensee agrees to ensure that laundry detergent is not left accessible to residents on care. Licensee shall conduct a staff training on the requirement and submit signed and dated staff attendance sheet as proof of correction.

Type B

Section Cited

HSC

1569.618(c)(3)

Other Provisions

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA record review the licensee did not comply with the section cited above in 5 of 6 staff files which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/10/2025
	Plan of Correction
1 2 3 4	Licensee will ensure that all staff have current first aid training on file. Licensee shall send LPA proof of first aid training for 5 staff as proof of correction.

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:

Lauren Crocker

LICENSING EVALUATOR NAME:

Rebecca Knight

LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025

LIC809 (FAS) - (06/04)

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