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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 312700033
Report Date: 04/08/2022
Date Signed: 04/08/2022 04:21:15 PM

Unsubstantiated


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
01/03/2022 and conducted by Evaluator Mai Thao
COMPLAINT CONTROL NUMBER: 25-AS-20220103105557
FACILITY NAME:GRANITE BAY COUNTRYHOUSE LLCFACILITY NUMBER:
312700033
ADMINISTRATOR:JANELLE LOPEZFACILITY TYPE:
740
ADDRESS:8485 BARTON RDTELEPHONE:
(916) 899-6565
CITY:GRANITE BAYSTATE: CAZIP CODE:
95746
CAPACITY:49CENSUS: 19DATE:
04/08/2022
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Jessica Sanders, AdministratorTIME COMPLETED:
04:25 PM
ALLEGATION(S):
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9
Staff handle residents in a rough manner
Staff leave residents in wet clothing and dirty diapers for extended periods of time
Insufficinet staffing
INVESTIGATION FINDINGS:
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3
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5
6
7
8
9
10
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13
On 4/8/2022, Licensing Program Analysts (LPAs) Mai Thao and Lavinia Muscan arrived at the facility unannounced to conduct a Complaint Investigation Visit with the above allegations and met with Jessica Sanders, Administrator. Prior to visit, LPAs 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. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 Mask and surgical mask.

During today’s visit, LPAs conducted interviews and delivered findings.

(Continue 9099-C…)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Mai ThaoTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022
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-20220103105557
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: 04/08/2022
NARRATIVE
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Staff handle residents in a rough manner

5 of 8 residents who were interviewed were not able to tell LPAs if they witnessed or have been handled in a rough manger due to diagnosis of Dementia and/or refused. 3 of 8 residents stated in interviews that they have not witnessed and have not been handled in a rough manner. Staff stated in interviews that they have not witnessed other staff handling residents in a rough manger. Staff who were interviewed (6 of 6) stated that they have not handle residents roughly. Administrator stated in interviews that there aren’t any staff that handles resident in a rough manner. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Staff leave residents in wet clothing and dirty diapers for extended periods of time

5 of 8 residents who were interviewed were not able to tell LPAs if they were left in wet clothing and dirty diapers for an extended periods of time due to diagnosis of Dementia and/or refused. Resident 1 (R1) stated in interviews that R1 does not need assistance, but staff are willing to assist if needed. Staff stated in interviews that occasionally staff will find a resident soaked during the start of their shift but will immediately assist resident. Staff 1 (S1) stated in interviews that S1 found Resident 2 (R2) soaked one time, but it was because R2 has a behavior of taking off R2’s briefs during the nighttime. Staff stated in interviews that when they find a resident wet, they will immediately assist the residents. Administrator stated in interviews that this rarely happens, when staff find a resident soiled, they immediately notify management and change the resident. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED

(continued 9099-C........)

SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Mai ThaoTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 25-AS-20220103105557
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: 04/08/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
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30
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32
Insufficient staffing

5 of 8 residents who were interviewed were not able to comment due to diagnosis of Dementia and/or refused. Resident 1 (R1) and Resident 3 (R3) stated in interviews that when they need assistance, they are always able to find someone to assist them. R1 and R3 reported no problem with staffing. Staff stated that the facility can use more staffing but are still able to meet all the needs of the residents in care. Staff stated in interviews that sometimes staff calls off, but there is always a substitute. Administrator stated that the facility utilizes an outside staffing agency and staff works overtime to meet the needs of the residents in care. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED

No citations were observed during the course of this investigation for the above allegations.

Exit interview was conducted and a copy of this report was left with Jessica Sanders, Administrator, whose signature on this document confirm receipt.

SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Mai ThaoTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022
LIC9099 (FAS) - (06/04)
Page: 3 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
01/03/2022 and conducted by Evaluator Mai Thao
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20220103105557

FACILITY NAME:GRANITE BAY COUNTRYHOUSE LLCFACILITY NUMBER:
312700033
ADMINISTRATOR:JANELLE LOPEZFACILITY TYPE:
740
ADDRESS:8485 BARTON RDTELEPHONE:
(916) 899-6565
CITY:GRANITE BAYSTATE: CAZIP CODE:
95746
CAPACITY:49CENSUS: 19DATE:
04/08/2022
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Jessica Sanders, AdministratorTIME COMPLETED:
04:25 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Untrained staff
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 4/8/2022, Licensing Program Analysts (LPAs) Mai Thao and Lavinia Muscan arrived at the facility unannounced to conduct a Complaint Investigation Visit with the above allegations and met with Jessica Sanders, Administrator. Prior to visit, LPAs 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. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 Mask and surgical mask.

During today’s visit, LPAs conducted interviews and delivered findings.

(Continue 9099-C…)
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Mai ThaoTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 25-AS-20220103105557
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: 04/08/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
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30
31
32
Untrained staff

LPAs reviewed 13 of 13 staff training files. LPAs observed that 13 of 13 have training on files. Staff stated in interviews that prior to starting, staff completes online training and shadowing another staff member before starting. Administrator stated that all staff are required to complete their online training and 16 hours of shadowing before they can start working on their own to assist residents in care. Administrator states that the facility conducts mandatory monthly staff in-service training. LPAs observed that facility have monthly training documentation on files. This agency has investigated the complaint alleging Untrained staff. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.

No citations were observed during the course of this investigation for the above allegation.

Exit interview was conducted and a copy of this report was left with Jessica Sanders, Administrator, whose signature on this document confirm receipt.

SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Mai ThaoTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5