312700033-1-29-2026-59-AS-MSEY-DRFQYK-20260219113512

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 312700033
Report Date: 01/29/2026
Date Signed: 01/29/2026 03:47:44 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
10/29/2025 and conducted by Evaluator Angela Hood

COMPLAINT CONTROL NUMBER: 59-AS-20251029114604

FACILITY NAME:	GRANITE BAY COUNTRYHOUSE LLC		FACILITY NUMBER:	312700033
ADMINISTRATOR:	PENA, MARIA		FACILITY TYPE:	740
ADDRESS:	8485 BARTON RD		TELEPHONE:	(916) 899-6565
CITY:	GRANITE BAY	STATE: CA	ZIP CODE:	95746
CAPACITY:	49	CENSUS: 43	DATE:	01/29/2026
		UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Kelly Blackwood, Acting Administrator		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

-Facility is not providing incontinence care
-Facility is not providing adequate food services
-Facility is not providing care and supervision to residents
-Facility is not providing supplies for personal care
-Facility staff did not follow reporting requirements
-Facility is in disrepair
-Facility staff did not seek medical attention for residents

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Angela Hood arrived at the care home today and met with the Acting Administrator, Kelly Blackwood, to deliver complaint investigation findings regarding the above stated allegations.

During the course of the investigation, LPA conducted interviews, made observations, and obtained documentation pertinent to the investigation.

*********************************************Continued on LIC9099-C***************************************************

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Angela Hood
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026

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 4

Control Number 59-AS-20251029114604

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: 01/29/2026

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: Facility is not providing incontinence care
Interview with hospice services indicated that they have no concerns regarding the facility providing resident (R1) incontinence care. Interview with staff (S1) indicated that R1 receives incontinent care every two (2) hours. Interview with staff (S2) indicated that they have never witnessed staff not providing incontinent care to residents that require assistance. Interview with staff (S3) indicated that all residents that require incontinent care are receiving assistance from staff. Interview with the Health and Wellness Director, Maria Pena, indicated that R1 requires incontinence checks every two (2) hours. The Health and Wellness Director indicated that resident (R2) will inform staff when they need to use the restroom. Also, staff cue resident to use the restroom. On November 7, 2025, LPA observed R1 and R2 to be clean as well as each resident having plenty of incontinent care supplies on hand for staff to provide care.

Allegation: Facility is not providing adequate food services
On November 7, 2025, LPA toured the kitchen area for the ability to prepare and store food. The kitchen appeared to be in good repair, and the care home had the required 2-day perishable and 7-day nonperishable food supply on hand. The meal menu for the month of November indicated a variety of food offered to the residents in care. LPA observed that the staff supply the bistro areas in the facility with snacks for the residents. LPA observed several residents eating in the dining room. LPA also observed S1 providing mealtime assistance to R1. Interview with hospice care services indicated that they have no concerns regarding R1’s eating habits. Interview with S2 indicated that residents are provided with adequate food services and have plenty of food options. Interviews with S3 indicated that they have never witnessed residents not receiving enough food and that residents are also offered snacks twice during a shift. Interview with resident (R3) indicated that the food services are good and the type of cooking is good. Interview with resident (R4) indicated that the food is good and that they are getting enough food.

Allegation: Facility is not providing care and supervision to residents
On November 7, 2025, LPA toured the facility and observed several residents eating in the dining room, watching television, and interacting with care staff. Residents appeared clean and LPA observed staff providing care to residents. R1 was receiving mealtime assistance from S1. R2 was interacting with staff in the dining room. Interview with S2 indicated that they have never witnessed staff not providing care and supervision. Interview with hospice services indicated that they have no concerns regarding staff providing care and supervision and that R1 always appeared clean. Interview with S2 and the Health and Wellness
**********************************************Continued on LIC9099-C*****************************************************

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Angela Hood
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 59-AS-20251029114604

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: 01/29/2026

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

Director, Maria Pena, indicated that laundry is constantly going and that showers are done on the residents scheduled shower days. S3 indicated that they have never witnessed residents wearing dirty clothing. S2, S3, the Health and Wellness Director indicated that soiled laundry gets done immediately. On January 29, 2026, LPA observed residents in the common areas to appear clean. LPA observed care staff interacting with residents. R3 and R4 appeared to be clean and wearing laundered clothing. Interview with R4 indicated that staff are conscious of their responsibilities to the residents and that they all seem to be doing the right thing. R4 indicated that they feel all of their care needs are being met. Interview with R3 indicated that staff provide good care.

Allegation: Facility is not providing supplies for personal care
On November 7, 2025, LPA observed the supply closet to be fully stocked with gloves, briefs, wet wipes, and bed pads. LPA also observed personal care supplies that the facility keeps on hand if a resident does not have their own such as, body soap, toothpaste, toothbrushes, shampoo, conditioner, and cotton balls. Interview with Executive Director, Kimberly Springer, indicated that the residents’ responsible parties typically provide hygiene supplies to residents. However, the facility has supplies on hand if a resident doesn’t have needed personal care products. LPA observed R1 and R2’s rooms to have locked cabinets that included all the residents’ personal care supplies. Interviews with S2 and S3 indicated that there are plenty of personal care supplies for the residents at the care home. Interview with R3 indicated that the facility will provide hygiene products. Interview with R4 indicated that, if they ask for supplies or the facility staff thinks that a resident needs them, the facility will provide personal care supplies to them.

Allegation: Facility staff did not follow reporting requirements
Interviews with S2 and S3 indicated that, when there is an incident with a resident, they inform a med tech on duty who will generate an incident report. S2 indicated that the caregivers will provide the information and record any observations of residents in the facility’s internal system. S3 indicated that, if a resident is receiving hospice care services, they will contact hospice. S3 also indicated that, if there is an incident, care staff assess the situation and will call paramedics or 911, if needed. S3 indicated that they will also inform the resident’s responsible party as well as the Wellness Director and/or the Executive Director. No specific incident was provided in the complaint. LPA has observed the facility to provide incident reports to the department.

*******************************************Continued on LIC9099-C***************************************************

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Angela Hood
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 59-AS-20251029114604

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: 01/29/2026

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: Facility is in disrepair
On November 7, 2025, LPA toured the facility which appeared to be clean and in good repair. LPA observed all the laundry rooms to be in good repair. There was one (1) stacked washer and dryer on the second floor and five (5) stacked washers and dryers on the first floor. Interview with the Maintenance Director indicated that there have always been enough washers and dryers to get the laundry done in the care home. They indicated that the caregivers do laundry daily and that there are assignments to do laundry for specific residents each day. Interview with S2 indicated that there are six (6) washers and dryers, so there are plenty to get the laundry done even if one (1) went out. S3 indicated that there are six (6) functioning washer and dryers in the care home.

Allegation: Facility staff did not seek medical attention for residents
Interview with S2 indicated that they have never witnessed staff not providing timely medical attention for the residents in care. S2 stated that staff ensure residents are seen timely by a physician or are sent to the hospital, if needed. S3 indicated that, in an emergency, care staff will call 911 to ensure timely medical attention. S2 indicated that, if a resident receives hospice care services, staff will contact hospice. S2 indicated that, if there is an incident, care staff will assess the situation and act accordingly. If needed, staff will contact paramedics. Interview with hospice services indicated that they have no concerns regarding communication with the facility regarding residents that need medical attention. No specific incident was provided in the complaint.

Based on interviews conducted, observations made, and documentation obtained, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are UNSUBSTANTIATED. No deficiencies are being cited.
Exit interview conducted. A copy of the report was provided.

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Angela Hood
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026

LIC9099 (FAS) - (06/04)

Page: 4 of 4