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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 312700033
Report Date: 08/31/2021
Date Signed: 08/31/2021 03:20:23 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/15/2021 and conducted by Evaluator Konnor Leitzell
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20210415132948
FACILITY NAME:GRANITE BAY COUNTRYHOUSE LLCFACILITY NUMBER:
312700033
ADMINISTRATOR:ANDREA C ARMSTRONGFACILITY TYPE:
740
ADDRESS:8485 BARTON RDTELEPHONE:
(916) 899-6565
CITY:GRANITE BAYSTATE: CAZIP CODE:
95746
CAPACITY:49CENSUS: 24DATE:
08/31/2021
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Andrea ArmstrongTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Medications not administered as prescribed by physician
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Konnor Leitzell arrived at the facility unannounced on 8/31/2021 to deliver findings for a complaint Community Care Licensing (CCL) received on 4/15/2021 which alleged that “Medications not administered as prescribed by physician”. LPA met with Andrea Armstrong (Admin) and explained the purpose of the visit. Prior to entering, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted admin and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Masks. Additionally, LPA was screened by staff and answers were documented in their visitor screening log.

CONT on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Konnor LeitzellTELEPHONE: (916) 708-9618
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021
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 25-AS-20210415132948
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: GRANITE BAY COUNTRYHOUSE LLC
FACILITY NUMBER: 312700033
VISIT DATE: 08/31/2021
NARRATIVE
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Throughout the course of the investigation, CCL conducted interviews and reviewed documents. Interviews were conducted with Staff, Administrator, and R1’s Responsible Party (RP). Through documents reviewed, CCL noted R1 had a prescription for Seroquel 25mg oral tab. The Physician’s orders stating, “Take 1 tablet orally once daily at dinner as needed for agitation”, dated February 5, 2020. Through facility documents, CCL noted eight (8) times the medication was provided to R1 between October 2020 and April 2021 by S2 outside of prescribed time, all being prior to 4:00p.m. Documents show the prescription being provided on 10/14/20 @ 10:45a.m.; 11/23/20 @ 8:45a.m.; 2/10/21 @ 3:47p.m.; 3/4/21 @ 11:25a.m.; 3/17/21 @ 9:44a.m.; 3/30/21 @ 1:12 p.m.; 4/4/21 @ 8:01a.m.; and 4/15/21 @ 8:19a.m.

When interviewing staff, CCL was informed R1’ schedule was to eat dinner at 5:00p.m. but the medication was provided prior to that time in order to control R1’s aggressive behaviors when assisting with ADLs. Interviews with S2 indicated they were aware of the physician’s orders stating the prescription was to be provided after dinner, but continued to provide R1 with the Seroquel outside of prescribed time.

Through interviews conducted, documents reviewed, and facility visits performed; CCL finds the allegation of “Medications not administered as prescribed by physician” to be SUBSTANTIATED - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

The following deficiencies are being cited on 9099-D, per Tittle 22 regulations: 87465(a)(5)- Incidental Medical and Dental Care..

Exit interview conducted with Andrea Armstrong (Admin). LPA provided admin with a signed copy of the report, along with the 9099-D. Appeal rights provided.

SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Konnor LeitzellTELEPHONE: (916) 708-9618
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 25-AS-20210415132948
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: GRANITE BAY COUNTRYHOUSE LLC
FACILITY NUMBER: 312700033
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/01/2021
Section Cited
CCR
87465(a)(5)
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87465(a)(5)- Incidental Medical and Dental Care-The licensee shall assist residents with self-administered medications as needed.
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Administrator agrees to conduct a training with all staff that handle medication. Training to include documentation, reviewing physician orders, and Extended Care Professional (ECP) for Electonic Health Records. Training provided to be sent into LPA by 9/2/2021.
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This requirement is not met as evidenced by: Based on observation and record review the licensee did not provide medication prescribed by physician which poses an immediate health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Konnor LeitzellTELEPHONE: (916) 708-9618
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/15/2021 and conducted by Evaluator Konnor Leitzell
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20210415132948

FACILITY NAME:GRANITE BAY COUNTRYHOUSE LLCFACILITY NUMBER:
312700033
ADMINISTRATOR:ANDREA C ARMSTRONGFACILITY TYPE:
740
ADDRESS:8485 BARTON RDTELEPHONE:
(916) 899-6565
CITY:GRANITE BAYSTATE: CAZIP CODE:
95746
CAPACITY:49CENSUS: 24DATE:
08/31/2021
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Andrea ArmstrongTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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2
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Facility’s lack of care and supervision resulted in resident’s fall.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Konnor Leitzell arrived at the facility unannounced on 8/31/2021 to deliver findings for a complaint Community Care Licensing (CCL) received on 4/15/2021 which alleged that “Facility’s lack of care and supervision resulted in resident’s fall”. LPA met with Andrea Armstrong (Admin) and explained the purpose of the visit. Prior to entering, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted licensee and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Masks. Additionally, LPA was screened by staff and answers were documented in their visitor screening log.

CONT LIC9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Konnor LeitzellTELEPHONE: (916) 708-9618
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021
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 25-AS-20210415132948
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: GRANITE BAY COUNTRYHOUSE LLC
FACILITY NUMBER: 312700033
VISIT DATE: 08/31/2021
NARRATIVE
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Throughout the course of the investigation, CCL conducted interviews and reviewed documents. Interviews were conducted with Staff, Administrator, and R1’s Responsible Party (RP). Through interview conducted, CCL learned that R1 was not a fall risk, and staff were near R1’s room when the fall occurred. CCL was informed that staffing was adequate the morning of the fall, and R1 was regularly monitored by caretakers. CCL was unable to determine that R1’s fall was due to lack of care and supervision.

Documents reviewed indicated R1 was not a fall risk at facility, and was ambulatory, not requiring a one on one assist. Although R1 was provided Seroquel the morning of the fall, outside of prescribed time; CCL is unable to determine R1’s fall was caused by the medication being administered outside of physician’s orders.

Through interviews conducted, documents reviewed, and facility visits performed; CCL finds the allegation of Facility’s lack of care and supervision resulted in resident’s fall to be UNSUBSTANTIATED. A finding that the allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. There are no deficiencies being cited per Title 22 Regulations, Division 6, Chapter 8. Exit interview conducted. A copy of this report was left at facility for review.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Konnor LeitzellTELEPHONE: (916) 708-9618
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5