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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405800987
Report Date: 10/10/2024
Date Signed: 10/10/2024 10:20:28 AM

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
10/04/2024 and conducted by Evaluator Mark Jeffries
COMPLAINT CONTROL NUMBER: 29-AS-20241004082045
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:
10/10/2024
UNANNOUNCEDTIME BEGAN:
07:02 AM
MET WITH:Licensee/Administrator, Angelita MaravillasTIME COMPLETED:
01:03 PM
ALLEGATION(S):
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Staff inappropriately restrained resident in care.
INVESTIGATION FINDINGS:
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 At 7:00 am on 10/10/2024, Licensing Program Analyst (LPA) Jeffries arrived unannounced to conduct a new complaint investigation visit, and issue final finding on two separate older complaints. LPA met with Licensee/Administrator, Angelita Maravillas, announced who he is and the reasons for the visit. LPA Jeffries conducted a cursory tour of the facility, conducted interviews, took photographs and video, reviewed, collected, and requested documentation. LPA Jeffries issued final findings to the allegations to this complaint as follows:

As to the allegation of, “Staff inappropriately restrained resident in care.” It was alleged that; resident was restrained by sheets that were tied down to the bed. It was discovered through interviews and admission that, On 10/07/2024, LPA Jeffries conducted a phone interview with Reliable Witness 1 (a person with license or credentials indicating expertise training and/or experience) RW1, who stated, when I arrived at the facility to assist my patient [Resident 1 (R1)], R1 was under the covers and there were sheets tied to the bed post that were restricting my patient (R1).” CONTINUED on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024
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 3
Control Number 29-AS-20241004082045
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: 10/10/2024
NARRATIVE
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RW1 stated that they untied sheet tied to the bed rails and called the staff into the room and asked why they were tied to the bed.” Staff 3 (S3) responded, “resident plays with their finesse.” RW1 told S3 that it was illegal to tie up and restrict residents and untied the remaining sheets from the bed. On 10/07/2024, LPA Jeffries conducted a phone interview with Reliable Witness 2 (a person with license or credentials indicating expertise training and/or experience) RW2 stated that, while visiting the facility on 10/04/2024, they interviewed Staff 1 (S1) who when asked about residents being tied to the bed by sheets, S1 stated, “they do that because (the resident) will dig in their fesses.” When S1 was asked by RW2, as a former Administrator at this facility, how could you let this happen? S1 stated “What’s the point? I just work here. It’s my aunt’s business. And they are going to do what they are going to do.” RW2 stated that S1 never disclosed staff which staff tied residents to their bed with sheets. On 10/10/2024 LPA Jeffries arrived at the facility and conducted interviews of Licensee/Administrator, Angelita Maravillas, who stated the R1 had stage 1 to 2 wounds on their buttocks, lower back, and ankles. Licensee/Administrator stated that she “knew it was wrong” but tied R1 down with the bed with sheet so R1 would not dig into their wounds on the buttocks and back. Administrator stated only she and S2 tied R1 down to the bed with bedsheet and no other staff participated in the restraint process with tying the R1 with a bed sheet to the bed rails. LPA Jeffries interviewed 4 of 4 residents. LPA noted that only 1 of 4 Residents were capable of a full cognitive conversation. At 9:02am on 10/10/2024, LPA Jeffries attempted to interview R1, when asked if they have ever been restrained by anyone in this facility, R1 replied, “I don’t know.” When asked if they had even been tied down in the bed at this facility R1 stated, “I don’t know.” At 9:13am on 10/10/2024 LPA Jeffries interviewed R2. R2 stated that they feel safe in the facility and has never been restrained and no personal rights issues have ever been violated in this facility by staff. At this time there is enough evidence by admission to the allegation of, “Staff inappropriately restrained resident in care.” And is substantiated at this time.

Exit interview, report read, citation issued, appeal rights and report provided.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20241004082045
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: 10/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/10/2024
Section Cited
HSC
1569.269(1)(a)(10)
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Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights: (1)To be accorded dignity in their personal relationships with staff, residents, and other persons.(10) To be free from neglect, ... punishment, humiliation, intimidation, and
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Licensee agrees to have all facility employees take 4 hours of Personal Rights, and Mandated Reporting Training conducted by and authorized vender of CCLD. Licensee must identify vender by 10/11/2024 and communicate with LPA in a timely manor
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verbal, mental, physical, or sexual abuse. Based admission the licensee did not comply with the section cited above by tying and allowoing S2 to tie R1 to the bed with a sheet, which poses a potential health, safety or personal rights risk to persons in care.
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as completion of all staff for all 4 hours of training required by this POC.
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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: 10/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024
LIC9099 (FAS) - (06/04)
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