297005250-6-19-2023-25-AS-MSEY-CSZM9H-20230621092443

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 297005250
Report Date: 06/19/2023
Date Signed: 06/19/2023 11:00:27 AM

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
01/24/2023 and conducted by Evaluator Melissa Parks

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20230124085504

FACILITY NAME:	ATRIA GRASS VALLEY		FACILITY NUMBER:	297005250
ADMINISTRATOR:	DANA STANSEL		FACILITY TYPE:	740
ADDRESS:	150 SUTTON WAY		TELEPHONE:	(530) 272-1055
CITY:	GRASS VALLEY	STATE: CA	ZIP CODE:	95945
CAPACITY:	116	CENSUS: 81	DATE:	06/19/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Natasha Georges		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Staff mishandled a resident's medication while in care

INVESTIGATION FINDINGS:

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LPA Parks arrived on June 19, 2023, to conclude a complaint investigation regarding the above allegation. LPA met with Administrator Natasha and explained the purpose of the visit.

Throughout the course of the investigation, LPA interviewed the Administrator, facility staff, corporate Nurse, another resident (R2) who manages their own medications, R1, and R1’s and health care providers (2). LPA reviewed R1’s file including R1’s MAR, centrally stored medication record, and resident self-injection assessment. LPA obtained copies of the Grass Valley Police Report and outside agency notes.

LPA learned that R1 managed their own medication. R1 called their healthcare providers when they realized that medication was missing. Facility staff were informed and searched R1’s room to look for the medication. Staff stated that R1 did not have an organized system for managing their medication. Staff found a full bottle of the missing medication. At this time, R1 expressed that they were experiencing increased neuropathy pain. Additionally, R1was noted to have increased sleepiness and confusion. Facility soon after

Unsubstantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa Parks	TELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023

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 25-AS-20230124085504

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: 06/19/2023

NARRATIVE

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began to manage R1’s medication. At the time of this complaint, there were no other instances of medication missing from residents who self manage.

Based on information obtained during the investigation, LPA finds the allegation to be UNSUBSTANTIATED- a finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred,

Exit interview. Appeal rights were printed and emailed. A copy of this report was emailed to the Administrator.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa Parks	TELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023

LIC9099 (FAS) - (06/04)

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