312700033-12-6-2023-59-AS-MSEY-CYMU45-20231218141428

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 312700033
Report Date: 12/06/2023
Date Signed: 12/06/2023 01:57:23 PM

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 LLC		FACILITY NUMBER:	312700033
ADMINISTRATOR:	JESSICA SANDERS		FACILITY TYPE:	740
ADDRESS:	8485 BARTON RD		TELEPHONE:	(916) 899-6565
CITY:	GRANITE BAY	STATE: CA	ZIP CODE:	95746
CAPACITY:	49	CENSUS: 25	DATE:	12/06/2023
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Jackie Hernandez		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff not supervising residents
Resident sustained multiple fractures due to staff neglect

INVESTIGATION FINDINGS:

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LPA Parks arrived on December 6, 2023, to deliver findings to two allegations from a complaint received on October 3, 2023. LPA met with Interim Executive DIrector Jackie Hernandez and explained the purpose of the visit.

Throughout the course of the investigation, current and previous staff were interviewed. LPA reviewed R1’s facility file including medication lists, incident reports, observation logs, MARs, care plans, and controlled substance count sheets. The result of the investigation is as follows:

R1 sustained two falls on 8/27/2022 and 5/29/2023 that resulted in serious injuries. The 8/27/2022 fall was a witnessed fall and R1 sustained a fractured left fibula and was placed in a split. Per the observation notes, R1 was attempting to walk on their own and collapsed on the floor. The 5/29/2023 fall was an unwitnessed fall and R1 sustained a “nondisplaced hairline fracture of radial head.” Per R1’s observation notes and Incident Report, R1 was found outside in the pond by their spouse. Staff were unable to provide a time frame as to how long R1 was outside for and staff did not know how R1 got outside.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa Parks	TELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023

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

LIC9099 (FAS) - (06/04)

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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: 12/06/2023

NARRATIVE

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Per the South Placer Fire District Prehospital (SPFD) Care Report, it was
noted that staff reported R1 may have fallen into the water about an hour prior to SPFD being dispatched to Granite Bay CountryHouse LLC.

After reviewing observation notes, it was determined R1 had approximately six witnessed falls and 12 unwitnessed falls, between 4/10/2022 to 8/30/2023. With the number of falls R1 had, staff were asked what they were doing to prevent R1 from falling. Staff indicated they were just “keeping an eye” on R1. R1’s care plans dated 2/25/2022 and 10/5/2023 noted that R1 requires two safety checks during the nighttime. However, the care plans did not indicate any special checks throughout the day or indicate that R1 was considered a fall risk. Per the Hospice “IDT” notes dated 11/17/2022, R1 was noted to become more dependent on care and can no longer walk due to wheelchair bound restriction. Additionally, it was noted on 11/4/2022, that R1 was a fall risk due to their fractured left foot. Staff reported that there are no specific procedures if a resident is considered a fall risk.

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

An immediate civil penalty in the amount of $500.00 is to be assessed for a resident sustaining a serious bodily injury while in care at this facility. As a result of resident’s injury, the violation warrants a civil penalty assessment based on Health and Safety Code §1569.49. At this time, the civil penalty assessment is under review. LPA will return at a future date to assess a civil penalty, if warranted.

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 Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa Parks	TELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

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: 12/06/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 12/07/2023 Section Cited CCR 87705(c)(4)	1 2 3 4 5 6 7	87705 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. .	1 2 3 4 5 6 7	Facility to submit detailed plan of measures put into place of staff identifying unmet needs and how the facility will address it. Additonally, plan will detail meeting needs of wander risks.
	8 9 10 11 12 13 14	current appraisal. This requirement was not met as evidenced by R1's safety needs not being met which allowed them to sustain an unwitnessed falls with fractures. This poses an immediate threat to the health and safety to residents in care.	8 9 10 11 12 13 14
Type A 12/07/2023 Section Cited CCR 87466	1 2 3 4 5 6 7	87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. . . .	1 2 3 4 5 6 7	Facility will submit detailed plan on proactive measures once a fall risk is indentified.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by the facility not providing R1 with appropriate safety measures as a fall risk. This poses an immediate threat to the health and safety to 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 Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa Parks	TELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023

LIC9099 (FAS) - (06/04)

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