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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002984
Report Date: 08/29/2024
Date Signed: 08/29/2024 12:55:53 PM

Document Has Been Signed on 08/29/2024 12:55 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:GRANITE MEADOW HOMEFACILITY NUMBER:
315002984
ADMINISTRATOR/
DIRECTOR:		JUDEE CASTROFACILITY TYPE:
734
ADDRESS:3115 GRANITE MEADOWS LNTELEPHONE:
(650) 580-3896
CITY:GRANITE BAYSTATE: CAZIP CODE:
95746
CAPACITY: 5CENSUS: 4DATE:
08/29/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:05 PM
MET WITH:Judee CastroTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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On 8/29/24, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit in response to a DDS monitoring audit report received 8/20/24 and met with Administrator, Judee Castro.

On 7/16/24, a DDS audit was conducted and the following deficiencies we noted at the facility:
CCR 22 ยง80065 (a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.
During observation, by DDS on 7/16/24, of gastrostomy tube feeding initiation for R1, staff (S1) did not measure the tubing or correctly assess for gastric residual prior to administering the water flush.
The licensed staff connected a syringe to the gastrostomy tube and unclamped the tube.
As observed by DDS RN insufficient time was given to allow gastric contents to go into the syringe to properly measure residual. Additionally,S1 did not measure the gastrostomy tubing length to confirm placement prior to administering the water flush.

This deficiency has been corrected by retraining of staff.

As a result of this inspection, the following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.

Report reviewed. Copy of report and appeal rights provided.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/29/2024 12:55 PM - It Cannot Be Edited


Created By: Kevin Mknelly On 08/29/2024 at 12:40 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GRANITE MEADOW HOME
FACILITY NUMBER: 315002984

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/12/2024
Section Cited
CCR
80065(a)

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80065 Personnel Requirements (a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs. This requirement was not met by observation of S1 incorrectly providing g-tube feeding
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Licensee had corrected this deficiency by retraining S1.
Licensee will submit proof of retraining conducted for S1 by the POC date of 9/12/24.
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on 7/16/24. This posed a potential risk to resident.
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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:Maribeth Senty
LICENSING EVALUATOR NAME:Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2024


LIC809 (FAS) - (06/04)
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