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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 317001251
Report Date: 08/23/2022
Date Signed: 08/23/2022 01:39:09 PM

Substantiated


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
01/20/2022 and conducted by Evaluator Michael Hood
COMPLAINT CONTROL NUMBER: 25-AS-20220120115924
FACILITY NAME:GRANITE SPRING CARE HOMEFACILITY NUMBER:
317001251
ADMINISTRATOR:TANYA FOKSHAFACILITY TYPE:
740
ADDRESS:5636 MONTCLAIR CIRCLETELEPHONE:
(916) 632-7473
CITY:ROCKLINSTATE: CAZIP CODE:
95677
CAPACITY:0CENSUS: 0DATE:
08/23/2022
UNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Natalya Foksha, LicenseeTIME COMPLETED:
01:55 PM
ALLEGATION(S):
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Facility staff are rough with resident while assisting with transfer
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Licensee, Natalya Foksha, to deliver findings into the allegation listed above. LPA wore an N-95 mask. Facility staff wore masks while on the premises.

During investigation, LPA conducted interviews and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

Allegation: Facility staff are rough with resident while assisting with transfer

** Report continued on 9099-C **
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: 916-531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2022
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-20220120115924
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 SPRING CARE HOME
FACILITY NUMBER: 317001251
VISIT DATE: 08/23/2022
NARRATIVE
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Interview with Administrator, Tanya Foksha, conducted on 1/26/2022 indicated that resident (R1) was paralyzed on one side and experienced fast transfer from wheelchair to bed. Administrator stated that R1 was “dead weight” because of paralysis and complained about fast transfer. Administrator stated that facility brought in a Hoyer Lift to assist R1 with transferring. However, Administrator stated that R1’s physical therapist (PT) did not want facility to use Hoyer Lift to allow R1 to work on not relying on lift.

LPA attempted to conduct an interview with PT from Sutter Care at Home – Roseville. However, PT would not share information pertaining to R1 with CCLD without written consent from R1 or R1’s authorized representative. R1 or R1’s authorized representative did not give written consent to PT to share information pertaining to R1’s treatment with LPA.

Interview with R1 conducted on 8/10/2022 indicated that staff member (S1) was rough with transferring R1 to and from bed and wheelchair. Interview with witness conducted on 8/10/2022 indicated that they observed S1 “throw” R1 in bed.

Interview with Licensee, Natalya Foksha, conducted on 8/11/2022 indicated that R1 received a 1-person assist with transferring from S1. Licensee stated that R1 would become stressed and noticeably upset after experiencing diarrhea. Licensee stated that S1 would conduct a fast transfer for R1 because R1 would become stressed and emotional after experiencing diarrhea. Licensee stated that the diarrhea and fast transfer took place "everyday" while R1 was receiving care at the facility.

Based on interviews conducted by the Department, 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 was conducted with Licensee. A copy of this report and appeal rights were provided. Licensee’s signature on these forms acknowledges receipt of these documents.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: 916-531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 25-AS-20220120115924
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 SPRING CARE HOME
FACILITY NUMBER: 317001251
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/07/2022
Section Cited
CCR
87555
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by:
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Facility will conduct a training with staff regarding transfer assistance. Licensee will also complete a statement of understanding regarding regulation 87468.2. Licensee will submit proof of staff training and statement of understanding to Department by POC due date of 9/7/2022
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Based on interviews conducted, the facility did not ensure that R1 received transfer assistance that met their needs, which poses a potential health, safety, and personal rights 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: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: 916-531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2022
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
01/20/2022 and conducted by Evaluator Michael Hood
COMPLAINT CONTROL NUMBER: 25-AS-20220120115924

FACILITY NAME:GRANITE SPRING CARE HOMEFACILITY NUMBER:
317001251
ADMINISTRATOR:TANYA FOKSHAFACILITY TYPE:
740
ADDRESS:5636 MONTCLAIR CIRCLETELEPHONE:
(916) 632-7473
CITY:ROCKLINSTATE: CAZIP CODE:
95677
CAPACITY:0CENSUS: 0DATE:
08/23/2022
UNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Natalya Foksha, LicenseeTIME COMPLETED:
01:55 PM
ALLEGATION(S):
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Facility staff have yelled at a resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Licensee, Natalya Foksha, to deliver findings into the allegation listed above. LPA wore an N-95 mask. Facility staff wore masks while on the premises.

During today’s visit, LPA conducted interviews and requested documentation pertinent to the investigation.

The results of the investigation are as follows:

Allegation: Facility staff have yelled at a resident

** Report continued on 9099-C **
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: 916-531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2022
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-20220120115924
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 SPRING CARE HOME
FACILITY NUMBER: 317001251
VISIT DATE: 08/23/2022
NARRATIVE
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Interview with witness indicated that they observed staff member (S1) yelling, screaming, and being disrespectful to residents in care. Interview conducted with resident (R1) indicated that people yell “at my face all the time.”

Interviews conducted with Licensee, Administrator, residents R2 and R3, and staff members S1 and S2 indicated that staff have not been observed being inappropriate or disrespectful to the residents in care. Interview with Licensee indicated that staff may speak loudly to residents who are hard of hearing to communicate with them.

Based on interviews conducted by the Department, the preponderance of evidence standards have not been met. Therefore, the above allegation is found to be UNSUBSTANTIATED. A finding that a complaint 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.

Exit interview was conducted with Licensee and a copy of this report was provided to the facility. The signature of the Licensee on these forms acknowledges receipt of these documents.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: 916-531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5