297005250-9-4-2025-59-AS-TORZ-DLNULV-20250919154120

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 297005250
Report Date: 09/04/2025
Date Signed: 09/04/2025 02:21:27 PM

Unsubstantiated

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
05/14/2025 and conducted by Evaluator Graham Gunby

COMPLAINT CONTROL NUMBER: 59-AS-20250514143905

FACILITY NAME:	ATRIA GRASS VALLEY		FACILITY NUMBER:	297005250
ADMINISTRATOR:	PHOEBIE CARCOT		FACILITY TYPE:	740
ADDRESS:	150 SUTTON WAY		TELEPHONE:	(530) 272-1055
CITY:	GRASS VALLEY	STATE: CA	ZIP CODE:	95945
CAPACITY:	116	CENSUS: 87	DATE:	09/04/2025
		UNANNOUNCED	TIME BEGAN:	08:54 AM
MET WITH:	Administrator - Joanna Lehman		TIME COMPLETED:	11:05 AM

ALLEGATION(S):

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Questionable Death
Resident sustained multiple fractures due to lack of care from staff
Staff touched resident inappropriately
Insufficient staffing to meet the needs of residents in care

INVESTIGATION FINDINGS:

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Licensed Program Analyst (LPA) Graham Gunby arrived at the facility unannounced and met with Joanna Lehman to deliver findings for the above complaint allegation.

During the investigation, LPA conducted interviews, conducted a tour of the facility, and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

*** Report continued on 9099-C***

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Graham Gunby
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025

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 59-AS-20250514143905

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: ATRIA GRASS VALLEY	FACILITY NUMBER: 297005250
	VISIT DATE: 09/04/2025

NARRATIVE

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Allegation 1: Unsubstantiated

On 01/18/2025 R1 was found on the floor in their bedroom, conscious and complaining of pain to their hip and should areas. R1’s immediate cause of death was cardiopulmonary arrest. R1 did suffer from a hip fracture and shoulder dislocation, but was not an underlying cause of death. R1 had a history of falls and not following the directions of their POA and caregivers. R1 was properly trained on how to use the pendant and to use the transfer pole correctly. Non-slip mats were also provided. Caregivers correctly documented the fall, but it is unclear if their assessment of the injuries caused additional damage. The Department was unable to review R1’s medical records due to an objection filed by F1.

Allegation 2: Unsubstantiated

Staff reported that R1 valued their independence and preferred to do their activities of daily living (ADL) independently. R1 was oriented to themself, place, and time and lived in Assisted Living. R1 received several checks throughout the day for continence assistance. R1 was able to transfer into and use their walker and wheelchair. There is a record from staff with their attempts to educate R1 on how to appropriately use their call pendant. Outside physical therapy staff reported on 1/14/2025, “R1 was able to ambulate/transfer to and from their wheelchair, without their front wheeled walker.” Residents and staff who were interviewed had no concerns with lack of supervision. F1 had no concern with the care provided by staff. F1 was in agreeance with R1’s care plan despite their history of falls.

Allegation 3: Unsubstantiated

During the course of the investigation the department attempted to contact R2 and their POA. During this time R2’s POA refused to communicate with investigators and did not want R2 to comment. R2 had sores present on the genital area that S1applied medication to. It was reported R2 felt S1 applied the medication too aggressively. After the report staff and residents reported no other allegations of inappropriate behaviors by S1.

SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Graham Gunby
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 59-AS-20250514143905

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: ATRIA GRASS VALLEY	FACILITY NUMBER: 297005250
	VISIT DATE: 09/04/2025

NARRATIVE

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Allegation 4: Unsubstantiated

LPA and IB investigated the allegation that “Insufficient staffing to meet the needs of residents in care.” Through interviews, 2 of 3 staff members stated that they feel they could use more help. Care staff explained the recent departure of many coworkers due to pay. 1 out of 3 staff said they have not felt the burden from the other care staff leaving. Through interviews with residents 3 out of 3 were not concerned with the level of care they are receiving.

Due to the information obtained, LPA finds allegation to be UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Graham Gunby
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025

LIC9099 (FAS) - (06/04)

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