312700033-4-29-2026-59-AS-LMUZ-DTZNM6-20260512103437

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 312700033
Report Date: 04/29/2026
Date Signed: 04/29/2026 05:17:16 PM

Substantiated

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
04/23/2026 and conducted by Evaluator Angela Hood

COMPLAINT CONTROL NUMBER: 59-AS-20260423145444

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: 38	DATE:	04/29/2026
		UNANNOUNCED	TIME BEGAN:	01:25 PM
MET WITH:	Kelly Blackwood, Acting Administrator		TIME COMPLETED:	04:20 PM

ALLEGATION(S):

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-Staff mismanaged resident's medications.

INVESTIGATION FINDINGS:

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

During today's visit, LPA conducted a medication count, reviewed/obtained documentation pertinent to the investigation, and conducted an interview.

LPA attempted to conduct a medication count for resident (R1) comparing the Centrally Stored Medication Log with the Medication Release form. However, a count could not be conducted as the Centrally Stored Medication Log was missing start dates. LPA conducted a medication count for residents (R2 & R3), comparing the residents' medication lists on file with the medication centrally stored for the residents.
********************************************Continued on LIC9099-C**************************************************

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Angela Hood
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20260423145444

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: 04/29/2026

NARRATIVE

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LPA observed one (1) medication for R2 to be over the documented amount and one (1) medication to be under the documented amount. R3 had three (3) medications that were under the documented amount.

On March 19, 2026, the department received an Unusual Incident/Injury Report LIC624 indicating that on March 4, 2026 the facility was notified that R1's medications were not being given as prescribed. The facility had nurses from an outside vendor conduct audits on all medications, which was concluded on March 18, 2026. The investigation/audit found that R1 was being given an incorrect dosage of medications. The facility indicated that they notified R1's primary care physician. The audit also found that start dates were not being consistently documented for several residents, some medications were expired, and some medications were not being stored as ordered.

Due to investigation/audit findings, the facility initiated a staff training for all Med Techs covering the job description, medication assistance procedures, and medication basics. The Acting ED indicated that all Med Techs were shadowed on the medication carts as well. The facility provided LPA with the sign off sheets for all staff that participated in the training as well as their final exams following the training. The facility took corrective action against staff involved in mismanaging residents' medications. The facility also terminated one staff after making an error following the retraining.

Based on a medication count, records reviewed and interview conducted, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page.

Exit interview conducted. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Angela Hood
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2026

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20260423145444

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/29/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/30/2026 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility (...) by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Facility agrees to conduct bi-weekly audits of all medications for the next two months and submit audits to LPA. The facility will split the audits up by wing in the facility. The last week of audits will be conducted the week of 6/28/26.
	8 9 10 11 12 13 14	Based on medication count and records reviewed, the facility did not ensure that residents (R1, R2, and R3) were receiving medications as prescribed, which poses an immediate health, safety, and personal rights risk to residents in care.	8 9 10 11 12 13 14	The facility has already provided LPA with copies of Med Tech training conducted the week of 3/23/26 as well as the medication audits concluded on 3/18/26.
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	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Laura Munoz
LICENSING EVALUATOR NAME: Angela Hood
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2026

LIC9099 (FAS) - (06/04)

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