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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200724
Report Date: 01/25/2023
Date Signed: 01/25/2023 03:21:17 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/09/2022 and conducted by Evaluator Catherine Lin
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20221109170058
FACILITY NAME:GRAND LAKE HOMEFACILITY NUMBER:
019200724
ADMINISTRATOR:THERESA BENIGNOFACILITY TYPE:
740
ADDRESS:365 STATEN AVENUETELEPHONE:
(510) 893-5308
CITY:OAKLANDSTATE: CAZIP CODE:
94610
CAPACITY:14CENSUS: 13DATE:
01/25/2023
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Veronica Guinto, AdministratorTIME COMPLETED:
02:25 PM
ALLEGATION(S):
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Facility staff did not seek medical attention for resident in a timely manner.
Facility staff did not reappraise resident for changes to their health condition.
INVESTIGATION FINDINGS:
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On 1/26/23 at 11:45am, Licensing Program Analyst (LPA) C. Lin arrived unannounced to conduct a subsequent complaint investigation visit for the above allegations and delivered investigation findings respectfully. LPA met with staff and informed the purpose of the visit. Administrator arrived at facility later.

Allegation: Facility staff did not seek medical attention for resident in a timely manner - Substantiated
The Department has investigated this allegation and per records review and interviews, found that resident R3 had glucose level test and was documented in a note book daily. R3's glucose level was significant increasing from "150" on 3/12/2022 to "204" on 3/13/2022, and remained in a fluctuating higher level in the rest of March and April, staff didn't notice it. When staff S1 noticed this change on 4/21/2022 then call R3’s physician on the same day, a new prescription was added to R3 on 4/22/2022. R3’s glucose level was remained in a higher level after taking the additional medication, facility staff didn’t notify physician again for further instruction.

Continue on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023
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 15-AS-20221109170058
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: GRAND LAKE HOME
FACILITY NUMBER: 019200724
VISIT DATE: 01/25/2023
NARRATIVE
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It was alleged that R3 had complained pain to staff, no supporting document was found.

Allegation: Facility staff did not reappraise resident for changes to their health condition - Substantiated
The Department has investigated this allegation and per records review and interviews, found that staff didn’t update reappraisal/needs and service plan (LIC625) for resident R3 when R3’s glucose level was significant increased. The latest LIC625 was dated on 2/27/2020.

Based on information obtained, the preponderance of evidence is met, therefore the allegations are substantiated.

Deficiencies are cited from Title 22 California Code of Regulations (see 9099D). Failure to submit proof of correction by plan of correction due date and/or any repeat violation within 12 month period may result in civil penalty.

Deficiencies and plan and proof of correction were discussed with the Administrator. Exit interview conducted. Appeal Rights, LIC9099D, and copy this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20221109170058
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: GRAND LAKE HOME
FACILITY NUMBER: 019200724
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/01/2023
Section Cited
CCR
87466
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87466 Observation of the Resident
The licensee shall ensure that residents are regularly observed for changes...that appropriate assistance is provided when such observation reveals unmet needs…..

This requirement is not met as evidenced by…
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Administrator agrees to retrain staff and submit in-service training to CCL by the POC due date.
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Based on records review and interview, the licensee did not comply with the section cited above. LPA observed staff didn’t monitor resident’s glucose level significant increasing which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
02/01/2023
Section Cited
CCR
87463(a)
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87463 Reappraisals
(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate….

This requirement is not met as evidenced by…
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Administrator agrees to review and understand regulation and submit a self-certification of being in compliance in future events to CCL by the POC due date.
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Based on records review and interview, the licensee did not comply with the section cited above. LPA observed staff didn’t reappraised resident when resident’s glucose level was significant increasing which poses/posed a potential health, safety or personal rights risk to persons 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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3