312700033-9-12-2024-59-AS-MSEY-D99S9M-20240919134059

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 312700033
Report Date: 09/12/2024
Date Signed: 09/12/2024 03:35:04 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
07/15/2024 and conducted by Evaluator Melissa Parks

PUBLIC

COMPLAINT CONTROL NUMBER: 59-AS-20240715152518

FACILITY NAME:	GRANITE BAY COUNTRYHOUSE LLC		FACILITY NUMBER:	312700033
ADMINISTRATOR:	JAMES HALL		FACILITY TYPE:	740
ADDRESS:	8485 BARTON RD		TELEPHONE:	(916) 899-6565
CITY:	GRANITE BAY	STATE: CA	ZIP CODE:	95746
CAPACITY:	49	CENSUS: 29	DATE:	09/12/2024
		UNANNOUNCED	TIME BEGAN:	03:45 PM
MET WITH:	James Hall		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff do not ensure the facility is free from pests.
Staff do not ensure the facility is clean.
Staff do not ensure laundry equipment is in good repair.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

LPA Parks and LPA Mikkelson arrived on Thursday September 12, 2024, to conclude a complaint investigation regarding the above allegations.

LPAs met with Administrator James Hall and explained the purpose of the visit. Throughout the course of the investigation, LPA interviewed the Administrator, Director of Nursing, and staff. LPA toured the facility with Administrator Hall. LPA reviewed pest control documentation. The result of the investigation is as follows:

Allegation: Staff do not ensure the facility is free from pests.
LPA interviewed staff who stated that they observed ants in R1’s room. Staff interviews also acknowledged that management has followed up with pest control and taken action in order to mitigate the issue. The facility supplied pest control invoices which show that the facility has routine pest control visits.

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: 09/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024

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 3

Control Number 59-AS-20240715152518

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: 09/12/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Allegation: Staff do not ensure the facility is clean.
LPA Parks and Administrator Hall toured the facility together. LPA did not observe any common area furniture which had been soiled by residents. LPA observed that the facility was relatively clean and organized. LPA toured resident rooms which also appeared to be clean and orderly. LPA learned that the facility’s full time housekeeping staff had recently quit without notice. In the interim of hiring a new housekeeper, the care staff are assigned to complete housekeeping tasks.

Allegation: Staff do not ensure laundry equipment is in good repair.
LPA toured the facility’s laundry room with Administrator Hall. Per interviews, 2 washers were in the process of being repaired or replaced. Facility has 3 laundry rooms throughout the facility which are accessible to staff. Staff interviews stated that there is sufficient washers and dryers to timely clean and return resident laundry.

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: 09/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

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
07/15/2024 and conducted by Evaluator Melissa Parks

PUBLIC

COMPLAINT CONTROL NUMBER: 59-AS-20240715152518

FACILITY NAME:	GRANITE BAY COUNTRYHOUSE LLC		FACILITY NUMBER:	312700033
ADMINISTRATOR:	JAMES HALL		FACILITY TYPE:	740
ADDRESS:	8485 BARTON RD		TELEPHONE:	(916) 899-6565
CITY:	GRANITE BAY	STATE: CA	ZIP CODE:	95746
CAPACITY:	49	CENSUS: 29	DATE:	09/12/2024
		UNANNOUNCED	TIME BEGAN:	03:45 PM
MET WITH:	James Hall		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff do not ensure hazardous items are inaccessible to residents.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

LPA Parks and LPA Mikkelson arrived on Thursday September 12, 2024, to conclude a complaint investigation regarding the above allegation.

LPA met with Administrator James Hall and explained the purpose of the visit. Throughout the course of the investigation, LPA interviewed the Administrator, Director of Nursing, and staff. The result of the investigation is as follows:
Allegation: Staff do not ensure hazardous items are inaccessible to residents.
LPA Parks interviewed staff. All staff interviews stated that they have never witnessed the medication room door being propped open without a staff being present. The medication door locks automatically when it closes. LPA did not observe any medications in resident rooms.Based on the evidence provided, the preponderance of evidence standards was not met, therefore, the above allegation is 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.

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: 09/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024

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 3