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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 312700033
Report Date: 03/23/2022
Date Signed: 03/23/2022 11:46:52 AM

Substantiated


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
09/22/2021 and conducted by Evaluator Todd Tryon
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20210922081544
FACILITY NAME:GRANITE BAY COUNTRYHOUSE LLCFACILITY NUMBER:
312700033
ADMINISTRATOR:ANDREA C ARMSTRONGFACILITY TYPE:
740
ADDRESS:8485 BARTON RDTELEPHONE:
(916) 899-6565
CITY:GRANITE BAYSTATE: CAZIP CODE:
95746
CAPACITY:49CENSUS: 20DATE:
03/23/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jessica Sanders, Executive DirectorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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- Staff do not administer medications to residents as prescribed by physician
- Residents are not properly supervised.
INVESTIGATION FINDINGS:
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Regarding the allegation that Residents are not properly supervised, LPA has
interviewed staff, reviewed documentation, toured the facility and observed residents.
On 12/15/2021 LPA Tryon and Investigator Burgoon were in the process of touring the
facility building with a staff member showing us around. Upon entering the dining room,
CCL staff noted that there were two residents present. One was sitting in a wheelchair
in front of a counter with a plate of food in front of him. His shirt/clothes appeared to be
covered in food. Another man was at the end of a table, standing up out of his
wheelchair, leaning half bent over at about a 90 degree angle over a plate of food on
the table. He appeared to be standing still in this position, not moving. There was no
staff nearby to be seen. Staff assisting with the tour then went to look for staff. It was
several minutes before staff came along. The staff working on the floor on that day
stated she worked for an agency. The two residents present were unsupervised for a
period of several minutes, during which time either one could have fallen or choked on
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022
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 8
Control Number 25-AS-20210922081544
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: 03/23/2022
NARRATIVE
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their food with no one present to witness or assist. Therefore, the allegation that
residents are not properly supervised is SUBSTANTIATED.
Regarding the allegation that staff do not administer medications to residents as
prescribed by physician, on 2/18/2022 LPA Tryon visited the facility to work on the
complaint. While there, LPA met with Angelica Rothhaupt, Wellness Director. Ms.
Rothhaupt and LPA did a medication review of 4 of 20 residents. In reviewing
medications present, MARS and daily computer Medication Logs, it was found that
there were two PRN (as needed) medications for resident R4 that were noted on
medication orders, but the medications were not present in the medication supply.
Therefore, if the resident had ever needed those 2 medications, the facility did not have
them available to give to R4 as prescribed. The allegation is SUBSTANTIATED.
A finding that an allegation is substantiated means that the allegation is valid because a
preponderance of the evidence standard has been met.
The following deficiencies are cited as per Title 22 Regulations. Appeal rights were
provided, exit interview conducted.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 8
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
09/22/2021 and conducted by Evaluator Todd Tryon
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20210922081544

FACILITY NAME:GRANITE BAY COUNTRYHOUSE LLCFACILITY NUMBER:
312700033
ADMINISTRATOR:ANDREA C ARMSTRONGFACILITY TYPE:
740
ADDRESS:8485 BARTON RDTELEPHONE:
(916) 899-6565
CITY:GRANITE BAYSTATE: CAZIP CODE:
95746
CAPACITY:49CENSUS: DATE:
03/23/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jessica Sanders, Executive DirectorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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- Resident inappropriately touches other residents
- Residents sustained injuries while in care
- Staff uses drugs at the Facility
INVESTIGATION FINDINGS:
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Regarding the resident inappropriately touching other residents, the Department has
investigated the allegation by reviewing documentation, interviewing staff, residents and
witnesses. It was found that the Physician Report for resident R1 did not indicate that
he had inappropriate or aggressive behaviors. His care plan did indicate that his
behavior patterns were to be monitored and staff should be aware of things that trigger
his agitation. It was reported by multiple staff that R1 would make sexual advances
towards another resident, R2. The other resident never reported any incidents to staff.
Per that R2’s Physician Report, R2 was able to communicate simple needs and follow
simple instructions. R2 did NOT display aggressive behaviors. One staff did report
seeing R1 touching R2, but R2 was reportedly smiling at the time. Several attempts
were made to interview R1, but due to his behaviors Department Staff was not able
interview R1. It was not possible to interview R2 as R2 had passed away by the time of
the investigation. Therefore, the allegation was found to be UNSUBSTANTIATED.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022
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 8
Control Number 25-AS-20210922081544
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: 03/23/2022
NARRATIVE
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Regarding the allegation that residents sustained injuried while in care, Department Staff reviewed facility records, medical records, interviewed staff and witnesses. It was learned that resident R3 did have an unwitnessed fall. Staff said that R3 was alone for approximately a half hour. R3 was sent to the ER. Medical records reported a closed displaced intertrochanteric fracture of left femur, other closed intra-articular fracture of distal end of left radius. R3 underwent hip surgery and a left write closed reduction. The responsible party for R3 reported no concerns for the care received at the facility. Department Staff interviewed R3, but R3 was unable to answer any questions. In interviewing staff, it was learned that R3 was not initially considered a fall risk and could independently move around. Physician report dated 5/4/2020 indicated R3 was able to independently transfer to and from bed and was ambulatory. Since R3’s fall, the Physician Report has been updated and R3 was noted to be a fall risk, and a sensor added to R3’s room. Allegation is UNSUBSTANTIATED.

Regarding the allegation that Staff uses drugs at the facility, the Department has interviewed staff. Staff denied witnessing other staff using drugs at the facility. It was learned that there were suspicions that certain staff were under the influence of drugs or had a smell that was thought to possibly be the smell of marijuana; or smelled “like a skunk.” It was found that the staff who allegedly “smelled like a skunk” never returned to work at the facility after the allegations were made. In speaking with the previous Executive Director, it was learned that there were concerns and allegations that another staff person was “under the influence” but the staff stated she was “tired.” That staff person was changed from a Medication Technician positive to a caregiver position. That staff never returned to work after questioned. Another staff interviewed said that “a lot of staff” thought another staff person was on drugs. However, it was never confirmed that any staff were ever actually under the influence of drugs while working. Therefore, the allegation is UNSUBSTANTIATED. A finding that an allegation is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 8
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
09/22/2021 and conducted by Evaluator Todd Tryon
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20210922081544

FACILITY NAME:GRANITE BAY COUNTRYHOUSE LLCFACILITY NUMBER:
312700033
ADMINISTRATOR:ANDREA C ARMSTRONGFACILITY TYPE:
740
ADDRESS:8485 BARTON RDTELEPHONE:
(916) 899-6565
CITY:GRANITE BAYSTATE: CAZIP CODE:
95746
CAPACITY:49CENSUS: DATE:
03/23/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jessica Sanders, Executive DirectorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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9
- Residents do not receive showers
- Staff do not assist residents with incontinence care
- Facility does not meet residents' nutritional needs
- Staff handles residents in a rough manner
- Facility does not maintain a disaster plan
- Facility is malodorous
- Facility is not maintained clean and sanitary at all times
- Facility is not maintained in good repair
INVESTIGATION FINDINGS:
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Regarding the allegation that residents do not receive showers, LPA has toured the facility, met with several residents, spoken with 12 of 22 staff, and reviewed documentation. In meeting with residents, all appear to be clean and groomed. In speaking with staff, LPA learned that residents are on a schedule to shower twice a week, some more often, depending on individual needs. Residents sometimes refuse to have a shower, and staff will then make several attempts during the shift to get them to shower, by trying later, having a different person try, etc. If the person does not have a shower when scheduled, staff let the next shift know so they can try. Overall, residents appear to be receiving showers on a regular basis. Therefore, the allegation is UNFOUNDED.
Regarding the allegation that staff do not assist residents with incontinence care, LPA met with several residents, spoken with 12 of 22 staff, and reviewed documentation. LPA learned that residents are checked regularly at least every couple of hours, and staff attempt to assist those residents who are able with toileting. Staff are aware of those residents who made need more frequent or extra assistance and monitor them. It appears that at this time, residents are changed when needed. Therefore, the allegation is UNFOUNDED.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 25-AS-20210922081544
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: 03/23/2022
NARRATIVE
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Regarding the allegation that the facility does not meet residents’ nutritional needs, LPA has viewed several meals at the facility, reviewed documentation, spoken with several residents and spoken with staff. There were no complaints regarding the food or nutrition, staff related that the food appears to be of good quality and nutrition, and portions are good. LPA observed the food to look appetizing and varied, and a good portion. The allegation is UNFOUNDED.

Regarding the allegation that staff handles residents in a rough manner, LPA has toured the facility, met with several residents, spoken with 12 of 22 staff, and reviewed documentation. Residents related that staff has not been rough. Although a few staff said they have seen other staff appear to be frustrated and speak sternly with a resident occasionally, no staff interviewed had ever personally seen any other staff treat a resident roughly; and no bruises such as fingerprints were ever documented. There was an incident reported last year when a new staff claimed to have seen another staff be rough while transferring a resident, but the situation was investigated, and no marks or bruises were found. Staff involved left employment after the allegation. Therefore, there is no evidence to support the allegation. Allegation is UNFOUNDED.

Regarding the allegation that facility does not maintain a disaster plan, LPA has reviewed facility documents, and found that the facility does in fact have a disaster plan present in the facility Therefore, the allegation is Unfounded.

Regarding the allegation that the facility is malodorous, LPA has visited the facility on 9/24/2021, 10/11/2021, 12/15/2021, 12/20/2021, 2/18/2021 and 3/10/2021. LPA has walked through the facility on each occasion. During these visits, the LPA noted no offensive odors of any sort at any place in the building. LPA cannot speak for times in the past, but the facility appeared to be odor free during visits since September 2021. Therefore, the allegation is Unfounded.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 25-AS-20210922081544
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: 03/23/2022
NARRATIVE
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Regarding the allegation that the facility is not maintained clean and sanitary at all times, LPA has visited the facility on 9/24/2021, 10/11/2021, 12/15/2021, 12/20/2021, 2/18/2021 and 3/10/2021. LPA has walked through the facility on each occasion. During these visits, the LPA noted the facility appeared to be clean, and free of odors. LPA cannot speak for times in the past, but the facility appeared clean and sanitary during visits since September 2021. Therefore, the allegation is Unfounded.

Regarding the allegation that the facility is not maintained in good repair, LPA has visited the facility on 9/24/2021, 10/11/2021, 12/15/2021, 12/20/2021, 2/18/2021 and 3/10/2021. LPA has walked through the facility on each occasion. During these visits, the LPA noted everything appeared to be in good repair. LPA did learn that the elevator to the second floor was having issues at some time in 2021, but the facility made an effort to have it repaired as quickly as possible. There were reportedly some technical issues, but it was repaired. LPA learned of no other issues. Therefore, the allegation is Unfounded.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 25-AS-20210922081544
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/24/2022
Section Cited
CCR
87465(a)(4)
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The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidence by: thru review of records and observation, it was learned that the facility did not have 2 medications for a resident that were ordered as a PRN (as needed)
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The facility will ensure that all medications that have been ordered by physician will be available in the facility for when they are needed.
Facility has already initiated regular medication audits. ED will submit a plan for on-going monitoring of medications by 3/24/2021.
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medication. If needed, they would not have been available
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Type A
03/24/2022
Section Cited
CCR
87411(a)
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Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...
This requirement is not met as evidenced by:
On 12/15/21 CCL staff witnessed 2 residents alone in the second floor dining area with no staff nearby. Both residents had food on the
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Facility will maintain adequate staffing to monitor residents and ensure safety. The facility has addressed this supervision issue by inviting second floor residents to spend time and eat on the first floor where there is more supervion available. ED will submit written plan of how resident monitoring will be addressed. Plan to be submitted by 3/24/22.
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table. One resident was standing bent over the table and could potentially have fallen or choked on food with no staff nearby; the other could have potentially choked.
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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.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022
LIC9099 (FAS) - (06/04)
Page: 8 of 8