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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 312700033
Report Date: 10/21/2022
Date Signed: 10/21/2022 03:23:08 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 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
04/18/2022 and conducted by Evaluator Lavinia Muscan
COMPLAINT CONTROL NUMBER: 25-AS-20220418133404
FACILITY NAME:GRANITE BAY COUNTRYHOUSE LLCFACILITY NUMBER:
312700033
ADMINISTRATOR:JESSICA SANDERSFACILITY TYPE:
740
ADDRESS:8485 BARTON RDTELEPHONE:
(916) 899-6565
CITY:GRANITE BAYSTATE: CAZIP CODE:
95746
CAPACITY:49CENSUS: 33DATE:
10/21/2022
UNANNOUNCEDTIME BEGAN:
02:27 PM
MET WITH:Sales Marketing Director, Kim EckertTIME COMPLETED:
03:40 PM
ALLEGATION(S):
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Lack of supervision led to resident injuries.
Staff failed to seek medical attention for a resident.
Staff not meeting resident needs.
INVESTIGATION FINDINGS:
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On 10/21/2022, Licensing Program Analysts (LPA) Lavinia Muscan and Licensing Program Manager (LPM) arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Sales Marketing Director, Kim Eckert . Prior to visit, LPA and LPM 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 and LPM 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**
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia MuscanTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022
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 3
Control Number 25-AS-20220418133404
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: GRANITE BAY COUNTRYHOUSE LLC
FACILITY NUMBER: 312700033
VISIT DATE: 10/21/2022
NARRATIVE
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Lack of supervision led to resident injuries. Per R1s Needs and Services Plan, R1 required regular checks (every two hours) during the nighttime or when R1s sensors would go off. R1 required full assistance with transfers. Per R1’s medical records, a Computed Tomography Scan (CT) was performed on 3/22/2022. The scan revealed that R1 had several areas of old vertebral compression fractures, old rib fractures, and findings consistent with chronic lung diseases. Per the Fire District Patient Care Report, it was noted that facility staff were unaware of R1s injuries. It was also noted that staff were informed of incident and the neglect of care. Per Executive Director, two staff members were both fired due to R1s incident. One staff member was fired for failure in job performance which resulted in a resident injury. It was reported that the staff watching R1 was laying on the couch on their cellphone and was not watching R1. The staff member denied seeing R1 fall, however, the same staff was able to explain how R1 fell. Staff reported that R1 was considered a fall risk. Based on the departments observations, interviews conducted, and record(s) reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) is/are found to be SUBSTANTIATED. California Code of regulations are being cited on the attached LIC9099D.

Staff failed to seek medical attention for a resident.


Staff not meeting resident needs.
Per the Unusual Incident/Injury Report, R1 had a fall on 03/18/2022. The staff on shift that evening did not call 911 nor was R1's reasonable party notified of R1's fall. On 03/21/2022, it was noted in facility observation notes, staff noticed R1 had bruising from the fall on Saturday 03/18/2022. The staff did not call 911 or advise R1s family of the bruising. It was not until 03/22/2022, where R1s family member went to visit R1 and noticed bruising on R1s chest. R1s family member questioned staff as to where R1s bruise came from. Staff told R1s family member that R1 had a fall on 03/18/2022. On 03/22/2022, R1 was sent out to the hospital. Per medical records, it was determined that R1 had several areas of old vertebral compression fractures, old rib fractures, and findings consistent with chronic lung disease. Per the facility's fall and reporting procedures, if a resident has a fall (or assumed fall) the medical professional will assess the resident. If the medical professional is not available for an assessment the resident will be transported to the emergency room for further evaluation. Additionally, it states, the resident's first emergency contact will be notified of the need for transportation and evaluation. Based on records and documentation, staff failed to seek medical attention for the resident and therefore the resident’s needs were not met. Based on the departments observations, interviews conducted, and record(s) reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) is/are found to be SUBSTANTIATED. California Code of regulations are being cited on the attached LIC9099D.

Appeal rights were provided. Exit interview was conducted with Administrator and a copy of this report was provided to the facility. The signature of Administrator on these forms acknowledges receipt of these documents.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia MuscanTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 25-AS-20220418133404
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: GRANITE BAY COUNTRYHOUSE LLC
FACILITY NUMBER: 312700033
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/24/2022
Section Cited
CCR
87465(g)
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87465(g) - Incidental medical and dental care services - 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... This requirement is not met as evidenced by:
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Licensee agrees to conduct staff training on initiating emergency services and reporting requirements.
Date of training shall be provided to LPA by 10/24/2022. Once training is completed, completion documentation and training topics to be provided to CCL.
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Based on interviews and records review it was determined that R1 fell on 3/18/2022 and EMS was not contacted. R1 was not taken to the ER until 3/22/2022. R1 sustained bruising which poses an immediate health and safety risk to residents in care.
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Type A
10/24/2022
Section Cited
CCR
87705(c)(4)
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87705(c)(4) - Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. This requirement is not met as evidenced by:
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Licensee agrees to conduct staff training on documenting and notification any residents change in conditions.
Date of training shall be provided to LPA by 10/24/2022. Once training is completed, completion documentation and training topics to be provided to CCL.
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Based on interviews conducted and record reviewed, the Licensee did not ensure that resident (R1) was supervised according to the care plan which posed an immediate health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia MuscanTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022
LIC9099 (FAS) - (06/04)
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