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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 585920293
Report Date: 08/26/2026
Date Signed: 08/26/2026 03:13:06 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
08/17/2026 and conducted by Evaluator Kerry Hiratsuka
COMPLAINT CONTROL NUMBER: 59-AS-20260817150650
FACILITY NAME:MARBELLA MARYSVILLEFACILITY NUMBER:
585920293
ADMINISTRATOR:JANELLE LOPEZFACILITY TYPE:
740
ADDRESS:515 HARRIS STREETTELEPHONE:
(530) 749-1786
CITY:MARYSVILLESTATE: CAZIP CODE:
95901
CAPACITY:72CENSUS: DATE:
08/26/2026
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Janelle LopezTIME COMPLETED:
03:20 PM
ALLEGATION(S):
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Staff are not following the admissions processes for residents
INVESTIGATION FINDINGS:
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LPA Hiratsuka conducted this unannounced complaint visit.

LPA interviewed Executive Director (ED). This allegation had to do with two residents who moved in and their medications being entered into the facility database. When a resident moves in their information is entered into an online database and a profile is created. Part of the profile is an electronic Medication Administration Record (MAR). Sometimes it takes a couple of days for the profile to be created and the med techs are to use a paper version of the MAR. For the two residents above this did not happen. The residents moved in, the profiles took a few days to be created, and the staff did not create the paper MAR per facility policy. However, the residents did get their medications as prescribed by the instructions on the labels. Because the med techs did not follow facility procedures the allegation is substantiated.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2026
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 4
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
08/17/2026 and conducted by Evaluator Kerry Hiratsuka
COMPLAINT CONTROL NUMBER: 59-AS-20260817150650

FACILITY NAME:MARBELLA MARYSVILLEFACILITY NUMBER:
585920293
ADMINISTRATOR:JANELLE LOPEZFACILITY TYPE:
740
ADDRESS:515 HARRIS STREETTELEPHONE:
(530) 749-1786
CITY:MARYSVILLESTATE:CAZIP CODE:
95901
CAPACITY:72CENSUS: DATE:
08/26/2026
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Janelle LopezTIME COMPLETED:
03:20 PM
ALLEGATION(S):
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Staff did not administer residents medication
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Hiratsuka, conducted this visit to deliver the results of the allegation above.

Community Care Licensing Division (CCLD) conducted the investigation into the allegations above.

LPA interviewed staff. The residents were getting their medications despite some confusion regarding paperwork with the residents moving in.

Based on information above, the department concluded that the allegations are Unfounded. A finding that an allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2026
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 4
Control Number 59-AS-20260817150650
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: 585920293
VISIT DATE: 08/26/2026
NARRATIVE
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As a result of this investigation, the Department finds the allegation above to be Substantiated. A finding that the complaint is Substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations.
Exit interview conducted. A copy of the report has been issued. LPA also left a copy of the Title 22 Regulation. Appeal Rights provided.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 59-AS-20260817150650
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: 585920293
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/26/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/25/2026
Section Cited
HSC
87208(a)
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87208. Plan of Operation The licensee shall have and maintain a current, written definitive plan of operation for the facility. The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so pursuant to Health and Safety Code
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By 09/25/2026, the licensee shall come up with a written plan of correction to ensure the resident's records are accounted for when residents are moved in.
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section 1569.49…This requirement not met as evidence by the facility based on interview which indicated staff did not create a paper MAR while waiting for the electronic profile to be crearted, which poses a potential 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 Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 4