312700033-10-1-2024-59-AS-MSEY-D9NTG6-20241002144237

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 312700033
Report Date: 10/01/2024
Date Signed: 10/01/2024 02:04:23 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
12/21/2023 and conducted by Evaluator Melissa Parks

PUBLIC

COMPLAINT CONTROL NUMBER: 59-AS-20231221093928

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: 27	DATE:	10/01/2024
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Goshong Vang, HR Coordinator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not properly assist resident with wound care.
Staff did not seek medical attention to resident as needed.
Staff did not provide a comfortable temperature to resident.
Staff did not communicate with resident's authorized representative in a timely manner.

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Melissa Parks arrived unannounced on Tuesday October 1, 2024, to complete and deliver findings to a complaint received on 12/21/2023. LPA met with Goshong and explained the purpose of the visit.

Throughout the course of the investigation, LPA interviewed the Administrator, staff, and hospice staff. LPA reviewed R1’s physicians report, death report, care plan, assessment, nursing notes, and outside agency notes. The result of the investigation is as follows:

Allegations: Staff did not properly assist resident with wound care. Staff did not seek medical attention to resident as needed.
LPA reviewed R1’s hospice notes. These were well documented nurse visits each time a hospice nurse visited R1 at the facility. Hospice notes always included any indication of pain and wound presence. LPA learned the following: R1 received weekly hospice visits which began around 10/12/2023 and ended when R1 passed in December. LPA reviewed nurse documentation on 11/13, 11/16, 11/22, 11/28,

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: 10/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024

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 2

Control Number 59-AS-20231221093928

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: 10/01/2024

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

11/30, 12/4, and 12/8. All these documented dates stated that R1 had no verbal signs of pain such as grimacing or frowning. Additionally, R1 had a documented stage 1 wound on their coccyx which was identified and staged on 10/12/2023. Each subsequent visit described the wound and treatment. This wound was always described as a stage 1 with instructions to use barrier cream and cover with a bandage. There were no documented notes of this wound progressing or worsening. On 11/16/2023, R1 had a new skin tear to the right linear arm, close to the elbow. Treatment was stated for staff to cleanse with wound cleanser and pat dry. On 11/30/2023, R1’s right heal was noted to be red. Hospice provided foot protectors for staff to use to keep pressure off the heal. All staff interviews stated that R1 never had an open pressure ulcer. Staff described redness and were instructed to frequently reposition R1 in bed to alleviate pressure. LPA interviewed R1’s primary hospice nurse who stated that R1 never had an open pressure ulcer. This hospice nurse stated that, to their recollection, there was no odor. Additionally, the hospice nurse stated that if R1 had a stage 3 or stage 4 wound, nurse visits would have occurred several times per week for treatment. LPA did not identify a medical emergency for R1. R1 had a gradual decline. Notes show that hospice staff and facility staff communicated throughout R1’s decline.

Allegation: Staff did not provide a comfortable temperature to resident.
LPA learned that each room could control their own thermostat. Staff interviews did not reveal that R1’s room was kept unusually hot or cold. LPA interviewed R1’s hospice nurse who did not recall R1’s room being kept at an uncomfortable temperature.

Allegation: Staff did not communicate with resident's authorized representative in a timely manner.
LPA learned that there were several managers who were assisting the facility while they were seeking a Director of Nursing and Executive Director. Leticia Higares, a Regional Director with the company, was assisting the facility while R1 was actively transitioning. Leticia stated that she spoke with R1’s POA after learning that they had called the facility. Observation notes detail when med techs called R1’s POA. Per staff interviews and observation notes, R1 had a gradual decline. Observation notes also detail frequent communication between the facility and R1’s hospice company.

Based on information obtained, 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 the evidence to prove that the alleged violation occurred.
Exit interview conducted. A copy of this report was left with the facility.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa Parks	TELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:	DATE: 10/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2