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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405800987
Report Date: 08/25/2022
Date Signed: 08/25/2022 02:44:08 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
08/22/2022 and conducted by Evaluator Mark Jeffries
COMPLAINT CONTROL NUMBER: 29-AS-20220822141607
FACILITY NAME:IRENE'S BOARD & CAREFACILITY NUMBER:
405800987
ADMINISTRATOR:ANGELITA O. MARAVILLASFACILITY TYPE:
740
ADDRESS:220 VIA PROMESATELEPHONE:
(805) 227-0276
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY:6CENSUS: 4DATE:
08/25/2022
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Licensee/Angelita MarvillasTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Facility staff member does not speak a language that resident can understand.
INVESTIGATION FINDINGS:
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 At 8:00am on 08/25/2022, Licensing Program Analyst (LPA)Jeffries arrived at the facility to issue final findings to the complaint allegations listed above. LPA met with Licensee, Angelita Marvillas.
As to the allegation of, “Facility staff member does not speak a language that resident can understand.” It was discovered that S3 and R1 were engaged in multiple aggressive verbal interactions at different times during the week of 08/15/22 through 08/22/22. One of the aggressive verbal interactions was overheard by S1, who was compelled to intervene and ended this aggressive verbal interaction. S1 stated that S3 was speaking in Tagalog during this specific verbal interaction. R1 is an English-only speaking resident and indicated that the other aggressive verbal interactions were spoken in Tagalog by S3. S3 did not admit to using any inappropriate names or profanity and S1 did not recall hearing any profanity in Tagalog (Tagalog is S1’s second language) and R1 is English only language. Based on the admissions of S3, and interviews, the allegation of, “Facility staff member does not speak a language that resident can understand.” is substantiated at this time.
Exit interview, Citation issued, report signed, appeal rights and report emailed.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2022
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 9
Control Number 29-AS-20220822141607
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: IRENE'S BOARD & CARE
FACILITY NUMBER: 405800987
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/31/2022
Section Cited
CCR
87468.2(a)(1)
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87468.2 Additional Personal Rights of Residents…(a)In addition to the rights listed in Section 87468.1, …shall have all of the following personal rights: (1)To have a reasonable level of …communications…This requirement was not met based on Staff
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All staff will receive 1 hour of resident personal rights training by an approved vendor. Licensee will submit proof of training to LPA Jeffries by email on or before 08/31/2022.
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admission of aggressive verbal interactions with Resident, which poses an potential health, safety and personal rights 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.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 9
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
08/22/2022 and conducted by Evaluator Mark Jeffries
COMPLAINT CONTROL NUMBER: 29-AS-20220822141607

FACILITY NAME:IRENE'S BOARD & CAREFACILITY NUMBER:
405800987
ADMINISTRATOR:ANGELITA O. MARAVILLASFACILITY TYPE:
740
ADDRESS:220 VIA PROMESATELEPHONE:
(805) 227-0276
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY:6CENSUS: 4DATE:
08/25/2022
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Licensee/Angelita MarvillasTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Facility administrator is not present at the facility.
Facility staff member called resident an inappropriate name.
Resident sustained bruising while in care.
Resident sustained a pressure injury while in care.
Facility staff member does not provide resident assistance when asked.
Facility is not following resident's care plan.
INVESTIGATION FINDINGS:
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 At 8:00am on 08/25/2022, Licensing Program Analyst (LPA)Jeffries arrived at the facility to issue final findings to the complaint allegations listed above. LPA met with Licensee, Angelita Marvillas.

As to the allegation of, “Facility administrator is not present at the facility.” It was discovered through observation and documentation that the Licensee/Administrator was on vacation in Germany from 08/07 through 08/21. During that time the facility was staffed by S1 who has a current Administrators Certificate and a submitted designation of responsibility (LIC308) form. During the period of 08/07 through 08/21, S1 was qualified to act as the designated temporary Administrator for this facility. Based on documentation and observation of S1 preset at the facility, the allegation of, “Facility administrator is not present at the facility.” is unsubstantiated, at this time.

CONTINUED on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 7 of 9
Control Number 29-AS-20220822141607
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: IRENE'S BOARD & CARE
FACILITY NUMBER: 405800987
VISIT DATE: 08/25/2022
NARRATIVE
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 As to the allegation of, “Facility staff member called resident an inappropriate name.” It was discovered that S3 and R1 were engaged in multiple aggressive verbal interactions at different times during the week of 08/15/22 through 08/22/22. On 08/21/22, One of the aggressive verbal interactions was overheard by S1, who was compelled to intervene and ended this aggressive verbal interaction. S1 stated that S3 was speaking in Tagalog during this specific verbal interaction. R1 is an English only speaking resident and indicated that the other aggressive verbal interactions were spoken in Tagalog by S3. S3 did not admit to using any inappropriate names or profanity and S1 did not recall hearing any profanity in Tagalog (Tagalog is S1’s second language) and R1 is English only language. Based on the interviews, there was not enough evidence to conclude that inappropriate language was used therefore the allegation of, “Facility staff member called resident an inappropriate name.” is unsubstantiated at this time. A personal right finding pertaining to the aggressive verbal interaction is addressed on a separate allegation to this complaint.

As to the allegation of, “Resident sustained bruising while in care.” It was discovered through interviews, admission, documentation, and observation that R1 has bruising on their right arm and back of the right leg. R1 stated they were not sure how the described bruising occurred. R1 also stated that Staff at the facility have no issue in transferring R1 from bed to wheelchair and none of the bruising on the arms or legs are from transferring. R1’s Primary second diagnosis is Hemiplegia, unspecified affecting right dominant side. Facility staff have all be trained in patient transfer basic techniques. Based on documentation, interviews, and observations there is not enough evidence to support the allegation of, “Resident sustained bruising while in care.” and is unsubstantiated, at this time.

As to the allegation of, “Resident sustained a pressure injury while in care.” R1 stated they have redness on the center of their buttock. R1 stated that the redness was there prior to admission to this facility in July 2022. Facility physical assessment documentation also indicates that R1 had, “redness in buttock area”. No other documentation states that R1 has a pressure injury. Licensee has a doctor’s appointment for R1 scheduled on 08/29/22 at 2:15pm, to ensure an appropriately skilled professional addresses the redness. Based on interviews, admission of R1 and documentation, there is not enough evidence to support the allegation of, “Resident sustained a pressure injury while in care.” and is unsubstantiated at this time.

CONTINUED on LIC9099-C
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2022
LIC9099 (FAS) - (06/04)
Page: 9 of 9
Control Number 29-AS-20220822141607
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: IRENE'S BOARD & CARE
FACILITY NUMBER: 405800987
VISIT DATE: 08/25/2022
NARRATIVE
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 As to the allegation of, “Facility staff member does not provide resident with assistance when asked.” It was discovered through interviews, observation, and admission that 3 of 4 residents currently living at the facility that were interviewed had no issues with staff providing assistance at any time during their stay at this facility. R4 was unable to have a meaningful interview due to current cognitive level. R1 stated that staff were always helpful and assisted when requested. A visiting family member of a current resident was interviewed on 08/23/22 and indicated that they have had no issues with the facility in any regard and does not believe their family member (Resident) has ever had their needs not met or been unable to be assisted by staff. S1 and S3 both stated that they are available to all residents while they are at the facility and in very limited circumstances a resident may have to wait for a caregiver to finish with another resident before assisting the request of the next resident. Staffing at the facility is at a 2:1 ratio during the hours of 7:00am until 10:00pm and 4:1 during the hours or 10:00pm until 7:00am. LPA observed residents’ requests for assistance being met during the visit from 8:10am through 1:09pm on 08/23/22. Based on interviews, observations, and admissions there is not enough evidence to support the allegation of, “Facility staff member does not provide resident assistance when asked.” and is unsubstantiated at this time.

As to the allegation of, “Facility is not following resident's care plan.” Based on documentation, interviews, admission and observation it was discovered that R1’s Appraisals Needs and Services Plan (LIC625) dated 07/30/22 and Physicians Report (LIC602A) dated 07/27/22 indicated that R1 was non-ambulatory and incontinent and required staff assistance in both areas as it pertains to this allegation. R1 stated that their needs were being met by staff, staff were able to transfer R1 to wheelchair and staff would change R1 at R1’s request. R1 also stated that all other needs were being met by the facility. On 08/23/22 at 8:09am, LPA observed R1’s request to be changed were being met as LPA was initially entering the facility. On 08/23/22, LPA observed S1 transferer R1 into wheelchair and move to the facility patio to allow R1 to smoke cigarettes. S1 and S3 stated that all residents’ needs are addressed in a timely manner, and as needed. Based on interviews, admission, observations, and documentation there is not enough evidence to support the allegation of, “Facility is not following residents care plan.” and is unsubstantiated at this time.


Exit interview, report singed, report emailed.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2022
LIC9099 (FAS) - (06/04)
Page: 8 of 9