312700033-5-3-2024-59-AS-MSEY-D4ZPH5-20240506111923

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 312700033
Report Date: 05/03/2024
Date Signed: 05/03/2024 02:42:42 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
04/12/2024 and conducted by Evaluator Melissa Parks

PUBLIC

COMPLAINT CONTROL NUMBER: 59-AS-20240412103029

FACILITY NAME:	GRANITE BAY COUNTRYHOUSE LLC		FACILITY NUMBER:	312700033
ADMINISTRATOR:	HIGARES, LETICIA		FACILITY TYPE:	740
ADDRESS:	8485 BARTON RD		TELEPHONE:	(916) 899-6565
CITY:	GRANITE BAY	STATE: CA	ZIP CODE:	95746
CAPACITY:	49	CENSUS: 28	DATE:	05/03/2024
		UNANNOUNCED	TIME BEGAN:	01:05 PM
MET WITH:	James Hall		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Staff did not assist resident with protective boot
Staff did not ensure that facility is free of pests

INVESTIGATION FINDINGS:

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LPA Parks arrived on Friday May 3, 2024, to conclude a complaint investigation regarding the above allegations.

LPA met with HR Assistant Goshong Vang and explained the purpose of the visit. Throughout the course of the investigation, LPA interviewed the Administrator, Director of Nursing, and staff. LPA reviewed observation notes for R1-R4. LPA reviewed pest control documentation. Additionally, LPA observed the apartments of R5 and R6 and the kitchen. The result of the investigation is as follows:

Allegation: Staff did not assist resident with protective boot
LPA reviewed R4’s hospice orders which stated that resident is to wear protective boots. LPA interviewed staff who stated that they always put the boots on R4. One interview acknowledged that agency staff have previously forgotten to put on the boots, but when observed by facility staff, this is corrected immediately.

Unsubstantiated

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: 05/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024

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 5

Control Number 59-AS-20240412103029

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: 05/03/2024

NARRATIVE

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Allegation: Staff did not ensure that facility is free of pests
LPA interviewed the facility Administrator who stated that there were ants observed by the beverage machine. The Administrator stated that this machine was then moved inside the kitchen, to prevent spills from residents. LPA reviewed pest control documents which stated that there was no evidence of pests in the facility. Facility staff interviews stated that they have not observed ants in the facility in a long time.

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 conducted. A copy of this report was provided to the facility.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa Parks	TELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 5

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
04/12/2024 and conducted by Evaluator Melissa Parks

PUBLIC

COMPLAINT CONTROL NUMBER: 59-AS-20240412103029

FACILITY NAME:	GRANITE BAY COUNTRYHOUSE LLC		FACILITY NUMBER:	312700033
ADMINISTRATOR:	HIGARES, LETICIA		FACILITY TYPE:	740
ADDRESS:	8485 BARTON RD		TELEPHONE:	(916) 899-6565
CITY:	GRANITE BAY	STATE: CA	ZIP CODE:	95746
CAPACITY:	49	CENSUS: 28	DATE:	05/03/2024
		UNANNOUNCED	TIME BEGAN:	01:05 PM
MET WITH:	James Hall		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Residents sustained unexplained bruising while in care
Staff did not provide adequate supervision, resulting in residents sustaining falls
Staff did not evaluate residents after sustaining falls
Staff did not provide residents with a healthful living environment
Staff neglected to care for resident’s injury
Staff did not ensure residents were provided adequate food services
Staff did not ensure furniture was clean and sanitized

INVESTIGATION FINDINGS:

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5
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LPA Parks arrived on Friday May 3, 2024, to conclude a complaint investigation regarding the above allegations.

LPA met with HR Assistant Goshong Vang and explained the purpose of the visit. Throughout the course of the investigation, LPA interviewed the Administrator, Director of Nursing, and staff. LPA reviewed observation notes for R1-R4. LPA reviewed pest control documentation. Additionally, LPA observed the apartments of R5 and R6. The result of the investigation is as follows:

Allegation: Residents sustained unexplained bruising while in care:
LPA interviewed staff who stated that they did not observe any bruising on R1-R4. Additionally, LPA reviewed observation notes for R1-R4, none mention bruising. LPA reviewed documentation which showed that R2 was diagnosed with a lipoma (fatty lump) which required no further treatment from their physician.

Unfounded

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: 05/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024

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 5

Control Number 59-AS-20240412103029

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: 05/03/2024

NARRATIVE

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Allegation: Staff did not provide adequate supervision, resulting in residents sustaining falls
After reviewing resident documentation, LPA did not find any evidence of falls due to lack of adequate staffing. Staff interviews discussed facility protocol if a residents falls are witnessed and unwitnessed. Interviews stated that the facility is utilizing agency staff in order for each shift to be fully staff. Additionally, interviews acknowledged that management will also assist on the floor when needed.

Allegation: Staff did not evaluate residents after sustaining falls
LPA reviewed observation notes for R1-R4. LPA reviewed detailed documentation by the Director of Nursing for a fall sustained by R1 on 3/8/2024. R1 was sent to the hospital for evaluation. Documentation detailed conversation with R1’s POA. Staff documentation noted that R1’s primary physician was notified. LPA did not find any documentation of falls for R2-R4. Additionally, staff interviews did not acknowledge any recent falls (within the last few months) for R2-R4.

Allegation: Staff did not provide residents with a healthful living environment
LPA observed R5 and R6’s apartments. Both apartments were tidy and well-maintained. LPA did not observe any feces in the bathroom or on personal items. LPA interviewed staff who stated that they have never observed feces in R5 and R6’s apartments. Additionally, staff stated that should a resident have an incontinence episode after housekeeping has left for the day, they have access to cleaning products.

Allegation: Staff neglected to care for resident’s injury
LPA reviewed R1’s documentation. No documentation revealed that R1 had an injury to the back of their head. Additionally, no staff interviews acknowledged that R1 had a head injury.

Allegation: Staff did not ensure residents were provided adequate food services
LPA interviewed staff who stated that there is a meal roster utilized for each meal. If residents are not at meals, staff then check on them. If residents do not want to eat in the dining room, there is a meal tray provided for them. All staff interviews stated that residents are, at a minimum, offered each meal. Residents can decline to eat. Additionally, interviews stated that R3 never missed three consecutive meals.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa Parks	TELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 59-AS-20240412103029

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: 05/03/2024

NARRATIVE

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Allegation: Staff did not ensure furniture was clean and sanitized
LPA toured the facility’s common areas and did not observe any stains or odors on the furniture. Staff interviews stated that if a resident soils a chair/cushion, that it is removed and sanitized. Interviews acknowledged that staff clean the soiled furniture, timely. LPA interviewed the Maintenance Director and Housekeeping which both stated that they routinely clean furniture and as needed.

Based on the evidence provided, the preponderance of evidence standards was not met, therefore, the above allegations are found to be UNFOUNDED. An unfounded allegation means that the allegation was false, could not have happened and/or is without a reasonable basis.

Exit interview conducted. A copy of this report was provided to the facility.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa Parks	TELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024

LIC9099 (FAS) - (06/04)

Page: 5 of 5