<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 312700033
Report Date: 12/14/2023
Date Signed: 12/14/2023 11:05:35 AM

Substantiated


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
10/03/2023 and conducted by Evaluator Melissa Parks
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20231003164146
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: 27DATE:
12/14/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jackie HernandezTIME COMPLETED:
11:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility disclosed resident confidential information to the wrong people.
Staff did not provide resident's authorized representative with records in a timely manner
Staff did not properly dispose of trash
Staff are not following medication orders.
Staff are not meeting residents' needs
Staff did not notify resident’s authorized representatives of incidents
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
LPA Parks arrived on Thursday December 14, 2023, to conclude a complaint investigation regarding the above allegations. LPA met with Interim Executive Director Jackie Hernandez and explained the purpose of the visit.

Throughout the course of the investigation, LPA interviewed the previous Administrator, previous Director of Nursing, Med techs, caregivers, dietary staff, and R1’s hospice nurse. LPA reviewed R1’s facility file including medication lists, MARs, and controlled substance count sheets. The result of the investigation is as follows:

Allegations: Facility disclosed resident confidential information to the wrong people and Staff did not provide resident's authorized representative with records in a timely manner
LPA reviewed emails between R1’s POA and the facility. The POA began requesting R1’s facility records on August 20, 2023. The POA sent a follow-up email on September 1, 2023, again requesting R1’s records. The facility emailed the POA some of R1’s file to the POA on September 5, 2023. The POA
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023
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 8
Control Number 59-AS-20231003164146
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: GRANITE BAY COUNTRYHOUSE LLC
FACILITY NUMBER: 312700033
VISIT DATE: 12/14/2023
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
26
27
28
29
30
31
32
followed-up on September 19, 2023 requesting R1’s full file including MARs, incident reports, etc. The POA received an email from the Director of Nursing on September 27, 2023, stating that they were working on compiling the file. According to the previous Administrator Jessica Sanders, all records requests are processed through the corporate office. The previous Administrator acknowledged that another resident’s information was accidentally provided to the POA of R1. Additionally, according to the timeline of emails and the interview with the previous Administrator, the facility provided R1’s requested facility records approximately 4 weeks after the initial request. Furthermore, once the requested documents were provided, there were documents for 5 other residents documents (R2-6) provided to the POA.

Allegation: Staff did not properly dispose of trash
The previous Administrator Jessica Sanders stated that R1’s POA was upset that once there was an instance of used incontinence products left in R1’s bathroom. Staff interviewed stated that R1’s room was normally kept tidy and clean. Interviews stated that the facility has dedicated housekeeping which deep cleans each room once per week. Care staff are responsible for cleaning accidents which may occur during the week. LPA also interviewed R1’s hospice nurse who stated that they would visit the facility twice per week. Per this hospice nurse, there were often where used incontinence products were discarded in the room or bathroom, rather than being taken to the trash. LPA was provided photos which show used incontinence products in R1’s room, outside of the trash can on several occasions.

Allegation: Staff are not following medication orders.
According to the reporting party, R1 was prescribed Lorazepam 1 mg every four hours as needed. The reporting party was told by a med tech that they were giving R1 this medication every four hours routinely. LPA reviewed R1’s scheduled and routine medications. According to the controlled substance count sheet, R1 began taking this medication in October of 2022 as PRN. LPA reviewed PRN MARs from May – September 2023. LPA also reviewed the facility’s controlled substance count sheet for this medication. According to the controlled substance count sheet, this medication was given as needed until 8/24/2023. On 8/24/2023 until 8/28/2023, R1 was given this medication at 7am each morning. According to R1’s hospice nurse, they spoke with staff and instructed them to give this medication as needed, and not routinely. LPA also identified that the MAR and controlled substance count sheet did not match. Staff were not correctly signing the MAR as this medication was given.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 59-AS-20231003164146
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: GRANITE BAY COUNTRYHOUSE LLC
FACILITY NUMBER: 312700033
VISIT DATE: 12/14/2023
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
26
27
28
29
30
31
32
Allegation: Staff are not meeting residents' needs
According to the interview with R1’s POA, R1’s incontinence needs were not met. The POA provided documentation which showed that several times they found R1’s bed soaked with linen. Additionally, interviews with staff stated they did the best they could, but R1’s incontinence needs were not always met timely. Additionally, staff interviews acknowledged that R1 would often have dirty clothes as they would spill food on themselves during mealtimes.

Allegation: Staff did not notify resident’s authorized representatives of incidents
During R1’s stay at the facility, they had had approximately six witnessed falls and 12 unwitnessed falls documented in observation notes. According to both the POA and hospice nurse, POA was not notified of every fall. Observation notes state that on 8/7/2023, R1 was found on the floor by care staff. Hospice was notified. POA arrived at the building after hospice notified them of the incident. Additionally, LPA’s interview with R1’s hospice nurse revealed that R1 had a fall on 9/1/2023. Again, R1’s POA was not notified of this fall until they received a call from the hospice nurse.

Based on the information detailed above, LPA finds the allegations to be substantiated. A finding that the allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies cited on 9099-D. Appeal rights were printed and given.

Exit interview conducted. A copy of this report was left at the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 59-AS-20231003164146
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: GRANITE BAY COUNTRYHOUSE LLC
FACILITY NUMBER: 312700033
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/15/2023
Section Cited
CCR
87465(c)(2)
1
2
3
4
5
6
7
87465 Incidental Medical and Dental Care (c)If the resident's physician . . . nonprescription PRN medication but can communicate his/her symptoms clearly,
(2) Once ordered by the physician the medication is given according to the physician's directions. This requirement
1
2
3
4
5
6
7
Facility to submit plan in regards to training staff for PRN medication regulations. Additionally, Facility will add auditing measures to ensure staff are following procedures.
8
9
10
11
12
13
14
was not met as evidenced by R1's PRN medication begin given routinely at 7am 8/24 - 8/28/2023. This poses a direct threat to the health and safety of residents in care.
8
9
10
11
12
13
14
Type A
12/15/2023
Section Cited
CCR
87625(b)(3)
1
2
3
4
5
6
7
Managed Incontinence
(3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement was not met as evidenced by R1's incontinence needs not being met as evidenced by soiled
1
2
3
4
5
6
7
Facility to submit date/time for training all staff in regards to incontinence needs being met.
8
9
10
11
12
13
14
bedding and clothings. This poses a direct threat to the health and safety of residents in care.
8
9
10
11
12
13
14
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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 59-AS-20231003164146
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: GRANITE BAY COUNTRYHOUSE LLC
FACILITY NUMBER: 312700033
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/28/2023
Section Cited
CCR
87468.2(a)(2)
1
2
3
4
5
6
7
87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (2) To have their records and personal information remain confidential and to approve their release, except as authorized by law. This requirement was not met as
1
2
3
4
5
6
7
Facility to submit a statement of understanding in regards to keeping residents information confidential.
8
9
10
11
12
13
14
evidenced by R1's POA receiving paperwork for other residents (5). This poses an indirect threat to the health and safety of residents in care.
8
9
10
11
12
13
14
Type B
12/28/2023
Section Cited
CCR
87468.2(a)(19)
1
2
3
4
5
6
7
87468.2 Additional Personal Rights of Residents in Privately Operated Facilities 19) To have prompt access to review all of their records and to purchase photocopies of their records. . . . (2) business days and at a cost that does not exceed the community standard for photocopies.
1
2
3
4
5
6
7
Facility to submit a statement of understanding regarding the timeline for residents to receive their documents.
8
9
10
11
12
13
14
This requirement was not met as evidenced by R1's repeated attempts to obtain R1's file while took approximately 4 weeks. This poses an indirect threat to the health and safety of residents in care.
8
9
10
11
12
13
14
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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 59-AS-20231003164146
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: GRANITE BAY COUNTRYHOUSE LLC
FACILITY NUMBER: 312700033
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/28/2023
Section Cited
CCR
87303(a)
1
2
3
4
5
6
7
87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. . This requirement was not met as evidenced by R1's soiled incontinence products being left throughout the room.
1
2
3
4
5
6
7
Facility to submit training records for staff regarding taking used incontinence products out of residents rooms, overall cleanliness etc.
8
9
10
11
12
13
14
This poses an indirect threat to the health and safety of residents in care.
8
9
10
11
12
13
14
Type B
12/28/2023
Section Cited
CCR
87468.1(a)(8)
1
2
3
4
5
6
7
87468.1 Personal Rights of Residents in All Facilities (8) To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs. This requirement was not met as evidenced
1
2
3
4
5
6
7
Facility to submit training records for med techs and Department heads are calling POAs in regards to falls and change of conditions.
8
9
10
11
12
13
14
by R1's POA not being notified of 2 falls. This poses an indirect threat to the health and safety of residents in care.
8
9
10
11
12
13
14
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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 8
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
10/03/2023 and conducted by Evaluator Melissa Parks
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20231003164146

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: DATE:
12/14/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jackie HernandezTIME COMPLETED:
11:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not providing adequate food service for residents
Staff are not meeting resident's laundry needs
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
LPA Parks arrived onThursday December 14, 2023, to conclude a complaint investigation regarding the above allegation. LPA met with Interim Executive Director Jackie Hernandez and explained the purpose of the visit.

Throughout the course of the investigation, LPA interviewed the previous Administrator, previous Wellness Director, Med techs, caregivers and kitchen staff. LPA reviewed R1’s facility file including medication lists, MARs, and controlled substance count sheets. The result of the investigation is as follows:

Allegation:Staff are not providing adequate food service for residents
LPA reviewed facility weekly menus from 4/2 until 9/24. Daily menus showed a variety of food for breakfast including scrambled eggs, sausage casserole, waffles, fruit of the day, and assorted hot and col cereals. Lunches showed a variety of entrees including pan seared fish, Shepards pie, meatloaf, and roast pork. Dinner showed a selection of entrees including spaghetti, crab salad, roast beef sandwich and teriyaki chicken burgers. Weekly menus show that fruit is available for breakfast. Additionally, each lunch
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 59-AS-20231003164146
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: GRANITE BAY COUNTRYHOUSE LLC
FACILITY NUMBER: 312700033
VISIT DATE: 12/14/2023
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
26
27
28
29
30
31
32
and dinner meal was served with a vegetable. Care and kitchen staff stated that fresh fruit and vegetables are served daily. Furthermore, staff stated that there is always extra food available should a resident want additional servings.

Allegation: Staff are not meeting resident's laundry needs
LPA interviewed care staff on all shifts in regards to R1 and their laundry needs. Staff interviewed stated that R1 required frequent clothing changes after meals. Additionally, R1 required incontinent care which sometimes led to a change of clothes. Staff stated that R1 always had dirty clothes to be laundered by the facility. However, staff interviewed also stated that R1 was never without clean clothes.

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

Exit interview. A copy of this report was emailed to the Administrator.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023
LIC9099 (FAS) - (06/04)
Page: 8 of 8