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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 312700033
Report Date: 06/17/2025
Date Signed: 06/17/2025 03:58:30 PM

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
01/13/2025 and conducted by Evaluator Graham Gunby
COMPLAINT CONTROL NUMBER: 59-AS-20250113151326
FACILITY NAME:GRANITE BAY COUNTRYHOUSE LLCFACILITY NUMBER:
312700033
ADMINISTRATOR:JAMES HALLFACILITY TYPE:
740
ADDRESS:8485 BARTON RDTELEPHONE:
(916) 899-6565
CITY:GRANITE BAYSTATE: CAZIP CODE:
95746
CAPACITY:49CENSUS: DATE:
06/17/2025
UNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Office Manager - Lorraine StaffordTIME COMPLETED:
02:40 PM
ALLEGATION(S):
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Facility staff are not properly administering medication to residents as prescribed
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Graham Gunby arrived unannounced on 06/17/2025 to complete and deliver findings to a complaint received on 01/13/2024. LPAs met with Office Manager, Lorraine Stafford and explained the purpose of the visit.

Throughout the course of the investigation, the department conducted interviews and record reviews.

Please continue to LIC9099C..
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Graham Gunby
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2025
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 59-AS-20250113151326
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: 06/17/2025
NARRATIVE
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Based on interviews and documents obtained, staff confirmed that hand-over-hand and live pouring the medications is the preferred process. Staff are also providing residents with a water cup and water dispenser while administering medications. During the visit on 04/18/2025 LPA observed med tech (S5) administer mediation to several residents using the live pour method. The facility also uses a 3rd party business to discard expired and unusable medication. The facility provided a copy of their bill which included the charge for discarding medication on 11/07/2024 and 03/07/2025. Through interviews with staff, all confirmed that if the resident is on hospice, that agency will dispose of their medications. If the resident is not on hospice, they will need multiple eyewitnesses and to sign off on the disposal. Based on interviews and records reviewed there is insufficient evidence to prove that facility staff is not properly administering medication to residents as prescribed causing residents to go to the ER due to lack of care.

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.

SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Graham Gunby
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2025
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
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
01/13/2025 and conducted by Evaluator Graham Gunby
COMPLAINT CONTROL NUMBER: 59-AS-20250113151326

FACILITY NAME:GRANITE BAY COUNTRYHOUSE LLCFACILITY NUMBER:
312700033
ADMINISTRATOR:JAMES HALLFACILITY TYPE:
740
ADDRESS:8485 BARTON RDTELEPHONE:
(916) 899-6565
CITY:GRANITE BAYSTATE: CAZIP CODE:
95746
CAPACITY:49CENSUS: DATE:
06/17/2025
UNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Office Manager - Lorraine StaffordTIME COMPLETED:
02:40 PM
ALLEGATION(S):
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Licensee does not ensure facility has a administrator on the premises to provide adequate attention to the facility
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Graham Gunby arrived unannounced on 06/17/2025 to complete and deliver findings to a complaint received on 01/13/2024. LPAs met with Office Manager, Lorraine Stafford and explained the purpose of the visit.

Throughout the course of the investigation, the department conducted interviews and record reviews.

Please continue to LIC9099C..
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Graham Gunby
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2025
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 59-AS-20250113151326
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: 06/17/2025
NARRATIVE
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Based on interviews and obtained documents, the previous administrator (S1) left abruptly just before 12/25/2024. During this time the facility facilitated a replacement administrator and begun the onboarding process. On their first day, the new administrator (S2) did not show up and the facility looked to hire an internal employee. The announcement for the new administrator (S3) was sent to residents and families and set for 02/27/2025. During this time, period the facility did have an active administrator (S4) with an approved Administrator Certificate. Records reviewed show the Administrator is at the facility an adequate number of hours. Additionally, the administrator stated that they devote additional hours to the facility to fulfill their responsibilities when the need for such additional hours is needed. This department has investigated the complaint alleging the administrator is not present at the facility to meet facility’s operational needs and found out that the allegation was UNFOUNDED.

Based on records reviewed, the above allegations are found to be UNFOUNDED. A finding that the allegations are unfounded means that the allegations are false, could not have happened, and/or is without a reasonable basis.

SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Graham Gunby
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4