280111959-4-22-2021-21-AS-BMOS-C2GQC4-20210427120230

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 280111959
Report Date: 04/22/2021
Date Signed: 04/22/2021 06:03:46 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/21/2021 and conducted by Evaluator Angela Elliott

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20210121145439

FACILITY NAME:	GREENHILLS CARE HOME, THE		FACILITY NUMBER:	280111959
ADMINISTRATOR:	GANTAN, KAM		FACILITY TYPE:	740
ADDRESS:	115 THAYER WAY		TELEPHONE:	(707) 558-8487
CITY:	AMERICAN CANYON	STATE: CA	ZIP CODE:	94503
CAPACITY:	24	CENSUS: 24	DATE:	04/22/2021
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Kam Gantan		TIME COMPLETED:	09:45 AM

ALLEGATION(S):

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Staff are not offering resident food
Staff did not ensure resident's mental health needs were met

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angela Elliott contacted Kam Gantan, Administrator by phone on this day for the purpose of delivering findings on complaint investigation. It is being conducted by phone due to COVID – 19 precautions.

There is an allegation staff are not offering resident food. LPA toured facility kitchen on 2/5/2021. Food supply observed was adequate for residents in care. Quality and quantity based on daily menu was also adequate. Multiple staff interviews consistently revealed R1 was offered food constantly and if a resident misses a general mealtime the kitchen is always open, and they can get food. Interview with outside party confirmed R1 often wanted to eat in their bedroom when eating became more difficult as part of their disease process. Outside party also confirmed staff offered R1 food multiple times a day. Outside party who often visited indicated R1 got to a point where they didn’t want to eat and observed staff offer R1 food on several occasions.
(See 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela Elliott	TELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20210121145439

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: GREENHILLS CARE HOME, THE	FACILITY NUMBER: 280111959
	VISIT DATE: 04/22/2021

NARRATIVE

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R1’s care plan reflects staff guidance-have to help with meals, holding cups for fluid and may need to feed. Care plan also states staff will continue to encourage nutrition and fluid, assist if necessary. Based on LPA's observations, interviews and record reviews the allegation is UNSUBSTANTIATED. An UNSUBSTANTIATED finding means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur.

There is an allegation staff did not ensure resident's mental health needs were met. Multiple staff interviews revealed emotional support was offered in a variety of ways. R1’s Care Plan reflects all staff will continue to reassure, support and connect with R1 to encourage comfort, decrease fear and a sense of permission to respect their right to chosen desire. Interview with outside party confirmed facility went above and beyond what is required, and caregivers are good about knowing what is going on with their patients. Outside party who often visited indicated the staff were very kind and understanding about what was going on with R1 and there were never any concerns. Based on LPA's observations, interviews and record reviews the allegation is UNSUBSTANTIATED. An UNSUBSTANTIATED finding means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur.

No citations issued for this allegation. This report was emailed to facility to obtain signature. Signature on file.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela Elliott	TELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2021

LIC9099 (FAS) - (06/04)

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