312700033-8-12-2022-25-AS-LMUZ-CHBTM4-20220815145030

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 312700033
Report Date: 08/12/2022
Date Signed: 08/12/2022 12:19:09 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/25/2022 and conducted by Evaluator Lavinia Muscan

COMPLAINT CONTROL NUMBER: 25-AS-20220125102307

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: 31	DATE:	08/12/2022
		UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Goshong Vang, Service Coordinator		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Facility not answering phones in a timely manner.
Staff not communicating with authorized representative.

INVESTIGATION FINDINGS:

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On 8/12/2022, Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Service Coordinator, Goshong Vang. Prior to visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured hand sanitizer was applied before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask.

During the investigation, the Department conducted interviews 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:

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Lavinia Muscan	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2022

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 4

Control Number 25-AS-20220125102307

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: GRANITE BAY COUNTRYHOUSE LLC	FACILITY NUMBER: 312700033
	VISIT DATE: 08/12/2022

NARRATIVE

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***Facility not answering phones in a timely manner.***
8 residents were interviewed. Majority of the residents who were interviewed were not able to communicate with LPAs due to diagnosis of Dementia and/or refused. Some residents interviewed stated that their loved ones are always able to call and get through to them. Administrator stated that if no one is at the front desk, the Med Techs have phones so they can answer during after-hours. LPA called the facility at various times and days and found staff to answer the phone. 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.

***Staff not communicating with authorized representative.***
LPA interviewed staff members who confirmed that they make themselves available to communicate with authorized representatives when needed. Staff stated that some conversations are documented in resident’s files depending on the information provided on the call. 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.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Lavinia Muscan	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/25/2022 and conducted by Evaluator Lavinia Muscan

COMPLAINT CONTROL NUMBER: 25-AS-20220125102307

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: 31	DATE:	08/12/2022
		UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Goshong Vang, Service Coordinator		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Medications are not given as per doctor order.
Staffing not sufficient to meet resident needs.

INVESTIGATION FINDINGS:

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***Medications are not given as per doctor order.***
Based on interviews conducted and records reviewed, the facility found an error in a resident’s medication order for an OTC PRN. Facility staff sent order back to physician for correct dosage on the weekend. Physician sent back order on the next business day. Based on investigation, facility administered medications to resident as ordered. This agency has investigated the complaint alleging (Medications not given as per doctor order). We have found the complaint was UNFOUNDED, meaning that the allegation is false, could not have happened, and/or is without a reasonable basis.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Lavinia Muscan	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2022

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

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 25-AS-20220125102307

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: GRANITE BAY COUNTRYHOUSE LLC	FACILITY NUMBER: 312700033
	VISIT DATE: 08/12/2022

NARRATIVE

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***Staffing not sufficient to meet resident needs.***
8 residents were interviewed. Majority of the residents who were interviewed were not able to communicate with LPAs due to diagnosis of Dementia and/or refused. Some residents stated in interviews that when they need assistance, staff are available to assist them. Residents did not indicate there is an issue with staffing. 6 staff members were interviewed. Staff interviews indicated that the facility can use more staffing, but staff are still able to meet all the needs of the residents in care. Staff stated that sometimes staff call off, but management will bring in a substitute. Administrator stated that the facility utilizes an outside staffing agency and staff work overtime to meet the needs of the residents in care. This agency has investigated the complaint alleging (staffing not sufficient to meet residents needs). We have found the complaint was UNFOUNDED, meaning that the allegation is false, could not have happened, and/or is without a reasonable basis.

Exit interview was conducted with Service Coordinator and a copy of this report was provided to the facility. The signature of the Service Coordinator on these forms acknowledges receipt of these documents.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Lavinia Muscan	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 4