Inspection Reports for
Marbella Marysville
515 HARRIS STREET, MARYSVILLE, CA, 95901
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
50% better than California average
California average: 4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Occupancy
Latest occupancy rate
60% occupied
Based on a October 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Annual Inspection
Capacity: 72
Deficiencies: 0
Date: Jan 14, 2026
Visit Reason
This was an unannounced annual inspection visit conducted by Licensing Program Analysts to evaluate the facility's compliance with licensing requirements.
Findings
The inspection found no deficiencies. The analysts toured the facility, reviewed staff and resident files, and discussed multiple topics with facility leadership.
Inspection Report
Complaint Investigation
Census: 43
Capacity: 72
Deficiencies: 2
Date: Oct 29, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that unqualified staff administered medication improperly and failed to keep accurate resident records.
Complaint Details
The complaint was substantiated based on interviews and record reviews. Staff administered medication improperly by putting it directly into residents' mouths and failed to document medication responses. An allegation about unqualified staff performing manual fecal impaction removal was unfounded.
Findings
The investigation substantiated that staff put medications directly into residents' mouths, which is against Title 22 regulations, and failed to document residents' responses to medications. Another allegation regarding manual fecal impaction removal by unqualified staff was found to be unfounded.
Deficiencies (2)
CCR 87465(a)(4): Staff put medications directly into residents' mouths, posing an immediate health and safety risk.
CCR 87465(c)(3): Staff failed to document residents' responses to PRN medications as required.
Report Facts
Capacity: 72
Census: 43
Deficiency Type A due date: Oct 30, 2025
Deficiency Type B due date: Nov 28, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tracy Freudendahl | Executive Director | Met with Licensing Program Analyst during investigation |
| Kerry Hiratsuka | Licensing Evaluator | Conducted the complaint investigation |
Inspection Report
Census: 39
Capacity: 72
Deficiencies: 1
Date: Oct 8, 2025
Visit Reason
This was an unannounced case management visit conducted in response to an incident reported by the facility regarding medication administration.
Findings
A medication technician refused to give two residents their as-needed medications despite the medications being in stock. An internal investigation was conducted, staff training was planned, and the residents did not suffer any ill effects.
Deficiencies (1)
CCR 87468.1(a)(1): A med tech refused to give residents their as-needed medications, posing a potential health and safety risk. The residents did not suffer any ill effects.
Report Facts
Census: 39
Total Capacity: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tracy Freudendahl | Executive Director | Reported the medication incident and internal investigation |
| Kerry Hiratsuka | Licensing Program Analyst | Conducted the inspection visit |
| Troy Ordonez | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 33
Capacity: 72
Deficiencies: 1
Date: May 6, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2025-02-25 regarding cleanliness of resident rooms, laundry issues, staffing sufficiency, and illness precautions at Marbella Marysville facility.
Complaint Details
The complaint investigation was substantiated for the allegation that staff do not keep resident rooms cleaned. Other allegations regarding laundry cleanliness and staffing sufficiency were unsubstantiated, and the allegation about illness precautions was unfounded.
Findings
One allegation regarding unclean resident rooms and bathrooms was substantiated, resulting in a cited deficiency. Allegations about laundry cleanliness and staffing sufficiency were unsubstantiated due to insufficient evidence. The allegation about staff not taking illness precautions was unfounded with no deficiencies cited.
Deficiencies (1)
CCR 87303(a) Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. Interviews revealed bathrooms were not cleaned and some rooms were not cleaned thoroughly, posing a potential health and safety risk to residents.
Report Facts
Facility Capacity: 72
Resident Census: 33
Deficiency Type B Count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tracy Freudendahl | Executive Director | Met with Licensing Program Analyst during investigation |
| Kerry Hiratsuka | Licensing Evaluator | Conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 33
Capacity: 72
Deficiencies: 1
Date: May 6, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations including medication(s) not given as prescribed, facility staff not meeting hygiene needs of a resident, insufficient staffing to meet resident needs, and food not served correctly.
Complaint Details
The complaint investigation was substantiated for medication errors but unsubstantiated for allegations related to hygiene needs, staffing sufficiency, and food service. The medication errors included one medication present but unknown to staff and eleven errors due to a med tech absence without coverage. No residents suffered ill effects, and doctors were notified.
Findings
The investigation substantiated the allegation of medication errors, with twelve medication errors reported in the past five weeks, posing an immediate health and safety risk. Other allegations regarding hygiene needs, staffing levels, and food service were unsubstantiated due to insufficient evidence.
Deficiencies (1)
CCR 87465(a)(5): The facility failed to develop and implement a plan for incidental medical and dental care, resulting in 11 medication errors that pose an immediate health and safety risk to residents.
Report Facts
Medication errors: 12
Facility capacity: 72
Resident census: 33
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tracy Freudendahl | Executive Director | Met with Licensing Program Analyst during investigation. |
| Kerry Hiratsuka | Licensing Evaluator | Conducted the complaint investigation. |
Inspection Report
Complaint Investigation
Census: 32
Capacity: 72
Deficiencies: 1
Date: May 6, 2025
Visit Reason
The inspection was conducted as a complaint investigation related to a resident's need for a hygiene device that was not addressed in the resident's care plan as required by Title 22 regulations.
Complaint Details
The complaint investigation 59-AS-20250414150539 found that a resident developed the need for a hygiene device to ensure comfort and reduce fall risk, but this was not addressed in the care plan.
Findings
The facility failed to update the resident's pre-admission appraisal to reflect the use of a hygiene device, posing a potential health and safety risk. A Type B deficiency was cited for not updating the appraisal as required by regulation.
Deficiencies (1)
CCR 87463(a): The pre-admission appraisal was not updated to reflect a resident's use of a hygiene device, posing a potential health and safety risk. This violates the requirement to update appraisals as frequently as necessary or at least every 12 months.
Inspection Report
Annual Inspection
Census: 32
Capacity: 72
Deficiencies: 0
Date: Jan 15, 2025
Visit Reason
This was an unannounced annual inspection visit conducted to evaluate the facility's compliance with licensing requirements.
Findings
No deficiencies were cited during the inspection. The facility is currently on a fire watch due to a fire panel issue reported early the same day, with the fire marshal involved in repairs.
Report Facts
Fire watch start time: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robert Coe | Executive Director | Met with during the inspection and provided information about the fire panel issue |
Inspection Report
Census: 29
Capacity: 72
Deficiencies: 1
Date: Jul 10, 2024
Visit Reason
The unannounced visit was conducted as a case management inspection focusing on deficiencies related to the facility's failure to report hosting evacuated residents from another facility during a wildfire evacuation.
Findings
The facility temporarily hosted residents evacuated from another facility due to the Thompson fire but failed to notify the Community Care Licensing Division as required by Title 22 regulations. This failure to report posed a potential health, safety, or personal rights risk to persons in care.
Deficiencies (1)
CCR 87211(a)(2): The licensee did not notify all Community Care Licensing offices when hosting evacuated residents, failing to report occurrences that threaten the welfare, safety, or health of residents within 24 hours as required.
Report Facts
Census: 29
Total Capacity: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Megan Sharp | Interim Executive Director | Interviewed during inspection regarding evacuation and resident care |
Inspection Report
Annual Inspection
Census: 37
Capacity: 72
Deficiencies: 0
Date: Jan 18, 2024
Visit Reason
This was an unannounced annual inspection visit conducted as part of the required yearly evaluation.
Findings
The facility was inspected with no deficiencies cited. Multiple topics were discussed during the visit.
Inspection Report
Complaint Investigation
Census: 39
Capacity: 72
Deficiencies: 0
Date: May 5, 2023
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that staff did not notify a resident's family of the resident's death.
Complaint Details
The complaint alleged that staff did not notify the resident's family of the resident's death. The allegation was found to be unfounded based on interviews and documentation review.
Findings
The investigation found that the facility notified the resident's Power of Attorney of the passing, meeting Title 22 reporting requirements. Therefore, the allegation was determined to be unfounded.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Parks | Licensing Program Analyst | Conducted the complaint investigation and delivered findings. |
| Sherri Banford | Health Services Director | Met with the investigator during the complaint investigation. |
Inspection Report
Annual Inspection
Census: 45
Capacity: 72
Deficiencies: 0
Date: Jan 5, 2023
Visit Reason
This was an unannounced annual inspection visit required by the licensing authority.
Findings
The inspection found no deficiencies. The facility was observed to be in compliance with regulations, including staff wearing surgical masks and proper screening procedures.
Inspection Report
Complaint Investigation
Census: 38
Capacity: 72
Deficiencies: 0
Date: Aug 2, 2022
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations that a resident hit and pushed another resident and that the facility was short staffed.
Complaint Details
The complaint involved allegations that a resident hit and pushed another resident and that the facility was short staffed. The investigation found the incidents occurred but could not determine the reasons. Staffing was deemed sufficient. The allegations were unsubstantiated.
Findings
The incidents of residents hitting and pushing each other did occur, but the reasons for these incidents could not be determined. The facility had records of monitoring the resident's behavior and contacting responsible parties. Staffing levels were found to be sufficient with no indication of a need for extra staff. The allegations were unsubstantiated.
Report Facts
Capacity: 72
Census: 38
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kerry Hiratsuka | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Census: 39
Capacity: 72
Deficiencies: 0
Date: Mar 16, 2022
Visit Reason
The visit was an unannounced case management visit conducted to follow up on incident reports involving a resident who was found on the floor multiple times and had a fractured pelvic.
Findings
The Licensing Program Analyst reviewed the resident's files, observed ongoing monitoring and updated care plans, and found no citations during the visit. The facility and resident's doctor are coordinating physical therapy.
Inspection Report
Annual Inspection
Census: 41
Capacity: 72
Deficiencies: 0
Date: Dec 27, 2021
Visit Reason
The inspection was an unannounced Required-1 Year Inspection focusing on the infection control domain to ensure health and safety compliance at the facility.
Findings
The facility was found to be in substantial compliance with no immediate health, safety, or personal rights violations observed. No deficiencies were cited as a result of the inspection.
Inspection Report
Census: 59
Capacity: 72
Deficiencies: 0
Date: Nov 23, 2021
Visit Reason
The visit was an unannounced case closure visit conducted by the Licensing Program Analyst to confirm the employment status of an individual and to complete required COVID-19 protocols.
Findings
No deficiencies were cited as a result of the visit. The Health Services Director reported that the individual named in the case closure was no longer working at the facility.
Inspection Report
Complaint Investigation
Census: 42
Capacity: 72
Deficiencies: 1
Date: Oct 7, 2021
Visit Reason
Unannounced complaint investigation visit regarding allegations that staff were not meeting residents' needs, mismanaging residents' medication, not providing laundry services, not providing adequate food service, and not notifying resident's authorized representative of change in condition.
Complaint Details
The complaint investigation was substantiated for failure to meet resident needs but unsubstantiated or unfounded for other allegations including medication mismanagement, laundry services, food service, and notification of authorized representative. The complaint was received on 2021-02-03 and investigated on 2021-10-07.
Findings
The complaint that staff failed to meet a resident's needs was substantiated due to failure to observe and provide appropriate assistance for changes in condition. The allegation of medication mismanagement was unsubstantiated. Laundry services and food service allegations were found to be unfounded or unsubstantiated. The allegation that staff did not notify the resident's authorized representative of a change in condition was unfounded.
Deficiencies (1)
CCR 87466 Observation of the Resident: The licensee failed to regularly observe a resident for changes in condition and provide appropriate assistance, posing an immediate health and safety risk.
Report Facts
Capacity: 72
Census: 42
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Audre Smith | Administrator | Met with during investigation and named in findings |
| Pheej Cheng | Licensing Program Analyst | Conducted the complaint investigation |
| Maribeth Senty | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 42
Capacity: 72
Deficiencies: 0
Date: Oct 7, 2021
Visit Reason
An unannounced complaint investigation visit was conducted regarding allegations that the licensee failed to ensure care and supervision causing a resident's hip fracture, failed to communicate with the responsible party, and failed to protect the resident's personal property.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included failure to provide care and supervision causing a hip fracture, failure to communicate with the responsible party, and failure to protect resident's personal property. The complaint was found unsubstantiated based on staff interviews, resident assessments, and documentation. The complaint was dismissed as unfounded.
Findings
The investigation found the allegations unsubstantiated. The resident did have a fall resulting in a hip fracture, but was not identified as a fall risk and staff reported no issues with ambulation. Communication with the responsible party was confirmed after the incident, and missing personal property could not be specifically identified or confirmed.
Report Facts
Capacity: 72
Census: 42
Date complaint received: Apr 8, 2021
Date of resident fall: Mar 1, 2021
Resident move out date: Mar 20, 2021
Admission agreement signed date: Aug 9, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Audre Smith | Administrator | Met with Licensing Program Analyst during complaint investigation |
| Pheej Cheng | Licensing Program Analyst | Conducted the complaint investigation visit |
Inspection Report
Complaint Investigation
Census: 42
Capacity: 72
Deficiencies: 2
Date: Oct 7, 2021
Visit Reason
An unannounced case management visit was conducted regarding deficiencies discovered related to complaint #25-AS-20210203091948.
Complaint Details
The visit was triggered by complaint #25-AS-20210203091948. The complaint was substantiated based on findings of failure to report a resident's change in condition and inaccurate medication records.
Findings
The facility failed to report a resident's change in condition to the responsible party, primary physician, and Community Care Licensing. Additionally, discrepancies were found in the resident's centrally stored medication record log, with missing dates and quantities not matching the electronic medication administration record.
Deficiencies (2)
CCR 87211(a)(1)(D) Reporting Requirements were not met as the facility failed to report a change of condition for one resident, posing a potential health and safety risk.
CCR 87465(h)(6) The licensee did not maintain accurate centrally stored medication records for one resident, posing a potential health and safety risk.
Report Facts
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Audre Smit | Administrator | Met with Licensing Program Analyst during the visit and discussed medication record discrepancies |
Inspection Report
Complaint Investigation
Capacity: 72
Deficiencies: 0
Date: Sep 22, 2021
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 07/22/2021 regarding staff roughness with a resident, a resident being left on the toilet for a long time, and staff coercing a family into admitting a resident to the facility.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff roughness with a resident, resident left on toilet for a long time, and staff coercion of family into admitting resident. Interviews and evidence did not support these claims.
Findings
After interviews with the Executive Director, staff, residents, and records review, all allegations were found to be unsubstantiated due to lack of evidence. No citations were issued at this time.
Report Facts
Facility Capacity: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Audre Smith | Administrator | Met with Licensing Program Analyst during complaint investigation |
| Misty Valencia | Licensing Program Analyst | Conducted the complaint investigation visit |
| Maribeth Senty | Supervisor | Supervisor overseeing the complaint investigation |
Inspection Report
Complaint Investigation
Capacity: 72
Deficiencies: 2
Date: Apr 21, 2021
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations including staff violating resident rights by posting a video of residents on social media and staff mismanaging resident medications.
Complaint Details
The complaint investigation was triggered by allegations that staff violated resident rights by posting a video of residents on social media and that staff were mismanaging resident medications. The video posting allegation was substantiated, while the medication mismanagement allegation was unsubstantiated due to lack of evidence.
Findings
The allegation of staff violating resident rights by posting a video on social media was substantiated, resulting in deficiencies cited under CCR §87468.1(a)(1) and H&S §1569.58(a)(2). The allegation of medication mismanagement was unsubstantiated based on interviews and record reviews.
Deficiencies (2)
CCR 87468.1(a)(1) Personal Rights of Residents: Licensee did not ensure Resident 1 was accorded dignity because staff recorded and posted a video of Resident 1 on personal social media without permission.
HSC 1569.58(a)(2) Persons prohibited from employment: Staff engaged in conduct inimical to the health, morals, welfare, or safety of Resident 1 by recording and posting a video on personal social media.
Report Facts
Facility Capacity: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brandy Strahl | Former Administrator | Stated that posting the video was against facility policy and confirmed termination of involved staff |
| Audre Smith | Administrator | Met with Licensing Program Analyst and confirmed no medication mismanagement |
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