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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405800987
Report Date: 12/11/2024
Date Signed: 12/12/2024 07:59:56 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
12/05/2024 and conducted by Evaluator Mark Jeffries
COMPLAINT CONTROL NUMBER: 29-AS-20241205160726
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:
12/11/2024
UNANNOUNCEDTIME BEGAN:
07:26 AM
MET WITH:Licensee/Administrator, Angelita O. Maravillas, TIME COMPLETED:
09:27 AM
ALLEGATION(S):
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Licensee does not ensure door exits in residents rooms are kept free of obstructions.
INVESTIGATION FINDINGS:
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 At 7:20am on 12/12/2024, Licensing Program Analyst (LPA) Jeffries arrived unannounced at the facility to conduct the initial investigation visit to the allegation to this complaint. LPA met with Licensee/Administrator, Angelita O. Maravillas, announced who he is and the reason for the visit. LPA conducted a tour of all resident rooms, conducted interviews, and issued final findings to the allegation to this complaint.

As to the allegation of, “Licensee does not ensure door exits in residents’ rooms are kept free of obstructions.” It was alleged that on 11/27/2024 a Reliable Witness 1 (W1) observed several obstacles blocking the resident room exit doors. It was discovered through interviews, and observations that on 11/08/2024 at 8:04am LPA Jeffries interviewed by phone Reliable Witness 2 (W2), who stated that facility had a Hoyer lift blocking the exit door in Resident Room #2. Additionally, on 11/18/2024 during the annual inspection LPA Jeffries had observed a 3-drawer nightstand dresser and boxes blocking the

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

DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024
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-20241205160726
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: 12/11/2024
NARRATIVE
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exit door to Resident Room #1.At the time Resident Room #1 had no residents currently occupying Resident Room #1. During that annual visit, on 11/18/2024 LPA verbally addressed the blocking of exits doors being a fire hazard (CCL 87203 State Fire Marshal, Chapter 10 CFC 1032.3 Required exits access, exits and exit discharges shall be continuously maintained and free of obstructions.[egress]) with the Licensee/Administrator, Angelita O. Maravillas, who acknowledge the fire hazard dangers, and moved items blocking Resident Room #1 exit doors. On 11/27/2024, W1 observed “numerous” items including, assistive medical devices/equipment, tray tables, large rolling garment racks, and stand-up assistance devices blocking sliding door exits. On 12/12/2024 at 7:45am LPA Jeffries conducted a facility tour observing Resident Rooms #2 with a Sara Steady lift partially blocking the exit door and Resident Room #4 with a chaise lounge couch partially blocking exit in room #4, LPA instructed Licensee/Administrator to permanently move both obstacles. At this time there is sufficient evidence to the allegation of, “Licensee does not ensure door exits in residents’ rooms are kept free of obstructions.” 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: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 29-AS-20241205160726
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: 12/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/25/2024
Section Cited
CCR
87203
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87203 Fire Safety, All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement was not met by evidence of W1, W2, and LPA observing Resident Room's exits being blocked by
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Licensee/Administrator, Angelita O. Maravillas, agrees to provided 2 hours of Fire Safety training from a CCLD authorized vendor to all staff by 12/27/2024 and email proof of training to LPA by 12/27/2024.
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obstacles, which poses a potential 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: 12/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024
LIC9099 (FAS) - (06/04)
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