312700033-7-14-2021-25-AS-MSEY-C4YVD9-20210716162022

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 312700033
Report Date: 07/14/2021
Date Signed: 07/14/2021 11:16:30 AM

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
07/12/2021 and conducted by Evaluator Bethany Mirlohi

COMPLAINT CONTROL NUMBER: 25-AS-20210712101825

FACILITY NAME:	GRANITE BAY COUNTRYHOUSE LLC		FACILITY NUMBER:	312700033
ADMINISTRATOR:	ANDREA C ARMSTRONG		FACILITY TYPE:	740
ADDRESS:	8485 BARTON RD		TELEPHONE:	(916) 899-6565
CITY:	GRANITE BAY	STATE: CA	ZIP CODE:	95746
CAPACITY:	49	CENSUS: 25	DATE:	07/14/2021
		UNANNOUNCED	TIME BEGAN:	09:34 AM
MET WITH:	Andrea Armstrong, Administrator		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Facility is in disrepair

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Bethany Mirlohi met with Administrator Andrea Armstrong during today's visit. During today's visit LPA opened allegation listed above. 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 they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Masks. Additionally, LPA was screened by staff, upon entering the facility.
LPA investigated allegation, "Facility is in disrepair". LPA toured the facility with administrator, and observed the upstairs and downstairs area including resident room, dining rooms, and common living spaces. LPA observed the facility to be clean and free from odor. LPA interviewed relevant party in which they stated facility air conditioning unit is not working in the upstairs dining room area and the elevator is not in working order.
Continuation on 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Mirlohi	TELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021

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 25-AS-20210712101825

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: 07/14/2021

NARRATIVE

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LPA interviewed administrator in which they stated the facility air conditioning in the upstairs dining room is not working however they have had an air conditioning company look into the issue and are actively working to fix the problem. While facility is waiting for the air to fixed in the upstairs dining, they have an additional siting room area that residents can use for meals upstairs, and a large dining room downstairs. Administrator stated the air conditioning throughout the facility, and in each residents room is in working order. During tour, LPA observed the temperature to be cooled to 75 degrees and residents appeared to be comfortable.
In addition, LPA interviewed administrator concerning the elevator. Administrator stated the elevator is in working order, however the fire signal system controlling the fire doors that are present outside of the elevator has been signaling a false alarm. When the alarm sounds, the fire doors close outside of the elevator. When this occurs staff have to turn off the alarm and reset the program. Facility has had a company look into the issue, and the company continues to work on the panel. Administrator stated during the weekend of July 2nd-4th, facility did not use the elevator out precaution. During the tour LPA used the elevator to access the 2nd floor and it was in working order. Administrator provided receipts and emails showing company is actively working on the issues. LPA observed a permit from Department of industrial Relations Division of Occupational Safety & Health issued on 7/1/21 for the use of the elevator.

LPA finds that the facility is having problems with the air conditioning in the upstairs dining room and the signal system which effects the elevator at times, however the facility is actively working on repairing the problems. LPA finds allegation to be UNSUBSTANTIATED.

Exit interview conducted.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Mirlohi	TELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021

LIC9099 (FAS) - (06/04)

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