312700033-12-30-2020-27-AS-BHUT-BWT23S-20201230160250

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 312700033
Report Date: 12/30/2020
Date Signed: 12/30/2020 04:03:58 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	GRANITE BAY COUNTRYHOUSE LLC		FACILITY NUMBER:	312700033
ADMINISTRATOR:	JANELLE LOPEZ		FACILITY TYPE:	740
ADDRESS:	8485 BARTON RD		TELEPHONE:	(916) 899-6565
CITY:	GRANITE BAY	STATE: CA	ZIP CODE:	95746
CAPACITY:	49	CENSUS: 32	DATE:	12/30/2020
TYPE OF VISIT:	Case Management - Legal/Non-compliance	UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Andrea Armstrong, Administrator		TIME COMPLETED:	04:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 12/30/20 Licensing Program Analyst (LPA) Bethany Huusfeldt, spoke with Administrator, Andrea Armstrong, of Granite Bay Country House LLC to follow up on a substantiated allegation of neglect/lack supervision. Due to COVID-19 precautions, LPA was unable to meet in person with administrator. On December 5, 2019, the Department concluded an investigation and Case Management visit. The Case Management visit was conducted in response to an allegation of an incident that occurred on October 6, 2019 where Resident 1 (R1) sustained injuries as a result of an unwitnessed fall. The allegation was substantiated, and the licensee was cited for violating California Code of Regulations (CCR) Title 22, § 87465(g) Incidental Medical and Dental Care: “(g) the licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health…” The licensee failed to call 9-1-1 in a timely manner. The licensee was also cited for violating California Health and Safety Statute § 1569.312(e) Basic Services requirements for failing to monitor the activities of R1 while R1 was under the supervision of the facility and ensuring the general health, safety and well-being. The investigation revealed R1’s medical evaluation report (LIC 602) diagnosed (R1) with dementia and documented that R1 was unable to leave the facility unassisted. Continuation on 809-C.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Huusfeldt	TELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:	DATE: 12/30/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2020

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

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: GRANITE BAY COUNTRYHOUSE LLC	FACILITY NUMBER: 312700033
	VISIT DATE: 12/30/2020

NARRATIVE

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In addition, R1’s care plan documented that he required 24-hour supervision and that R1 may not be able to find his way to an area of safety if he were to leave the secure environment and staff must maintain a secure environment by providing adequate supervision when R1 was outside of secure environment. Based on a preplacement appraisal it was documented that R1 had a history of getting lost and will need special observation specifically during night supervision. It also noted in R1’s needs and service plan that R1 needs monitoring and cueing with wandering. On October 6, 2019, R1, had an unwitnessed fall at the facility. On the same day, facility staff found R1 on the floor of a community restroom between 3:00 p.m. and 3:30 p.m. It is unknown how long R1 was on the floor. Additional staff were notified of R1’s fall and R1 was assisted into a wheelchair. R1 stated to staff there was pain in R1’s hip. Facility staff, medication technician (S1), did not send R1 to the hospital to be assessed and gave R1 a PRN Tylenol for the pain. Caregiver staff (S2) stated R1 came to S2 and stated that R1 was feeling a pulling sensation in R1’s upper thigh. S1 and S2 were told that R1 had pain yet neither staff called 9-1-1 to have R1 assessed by emergency medical staff. There is no facility documentation showing facility staff checked on R1 or asked R1 if R1 was in pain after PRN Tylenol was administered. On October 7, 2019 R1 woke up in extreme pain, when staff (S3) noticed at 6:00 a.m. that R1 could not move and was complaining about pain 9-1-1 was called. R1 was transported to a general acute care hospital on October 7, 2019 and later diagnosed with left hip fracture.

According to the incident report dated October 11, 2019, R1 was in extreme pain on October 7, 2019. Once at the hospital, R1 was diagnosed with a hip fracture. Interviews conducted with R1's responsible party revealed that R1’s responsible party was notified on October 7, 2019 that R1 was given PRN (as needed) medication for pain.

Continuation on 809-C.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Huusfeldt	TELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:	DATE: 12/30/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2020

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: GRANITE BAY COUNTRYHOUSE LLC	FACILITY NUMBER: 312700033
	VISIT DATE: 12/30/2020

NARRATIVE

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Based on observation, interview, and record review, the licensee did not seek timely medical treatment and provided basic services to R1. Facility staff failed to call 9-1-1 in a timely manner when the facility staff discovered that R1 had an unwitnessed fall. In addition, R1 did not receive medical attention until the day after the unwitnessed fall. As a result of the fall and neglect, R1 suffered extreme pain and was diagnosed with a hip fracture that required hospitalization which is a serious bodily injury.

At the time of the Case Management visit on December 5, 2019, an immediate civil penalty of $500 was issued and the licensee was informed that an additional civil penalty was still being determined and might be assessed based on Health and Safety Code § 1569.49.

The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code § 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including, but not limited to, hospitalization, surgery, or physical rehabilitation.”

Today, 12/30/20, the Department is issuing a civil penalty per Health and Safety Code § 1569.49 for a violation that the Department constitutes as a serious bodily injury in the amount of $10,000. However, since an immediate civil penalty of $500 was previously issued on December 5, 2019, the amount of the civil penalty issued today will be $9,500. A copy of the LIC 421D was given to Andrea Armstrong and originals were signed on file.

Exit interview conducted. A copy of the report issued. Appeal Rights provided. Andrea Armstrong signature on this report acknowledges receipt of the Appeal Rights, found on page two of LIC 421D.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Huusfeldt	TELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:	DATE: 12/30/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2020

LIC809 (FAS) - (06/04)

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