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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425802114
Report Date: 02/07/2023
Date Signed: 02/07/2023 06:00:08 PM


Document Has Been Signed on 02/07/2023 06:00 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:GRANVIDA SENIOR LIVING AND MEMORY CAREFACILITY NUMBER:
425802114
ADMINISTRATOR:BRANDY MCCAULEYFACILITY TYPE:
740
ADDRESS:5464 CARPINTERIA AVETELEPHONE:
(805) 566-0017
CITY:CARPINTERIASTATE: CAZIP CODE:
93013
CAPACITY:83CENSUS: 50DATE:
02/07/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Ted Burgess, Executive Director and Ashley Nash, Business Office DirectorTIME COMPLETED:
06:20 PM
NARRATIVE
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Licensing Program Analysts (LPA) Olson and Phillips conducted an unannounced case management visit to issue deficiencies after the facility had a COVID-19 outbreak and was told multiple times to report cases timely and submit incident reports. During today’s visit, LPAs met with Ted Burgess, Executive Director and Ashley Nash, Business Office Director and explained the reason for the visit.

On 12/2/22 and 12/5/22 LPA De Leon informed the facility that they must report COVID positives within 24 hours. On 12/12/22 the facility reported a COVID positive from 12/9/22 and on 12/19/22 the facility reported 2 positive COVID cases from 12/14/22.
Additionally, multiple LPA’s reminded the facility that they have 7 days to submit a written Incident report on all COVID cases and other serious incidents that occurred. On 12/16/22 CCL received 2 incident reports from 12/6/22 which is 10 days late. On 12/19/22 CCL received 8 incident reports ranging from 11/30/22 to 12/11/22 anywhere from 1 through 13 days late. CCL still hasn’t received multiple COVID positive incident reports.

Resident 1 (R1) Progress notes on 12/19/22 at 5:16AM state “Resident had a fall at 2am, (R1) seems to be confused, (Medtech 2) asked (R1) if anything hurt or if (R1) needed to be seen by the doctor. (R1) seemed in good spirits, refused pain and no visible wounds. We got (R1) up and into bed notified POA and Staff 1 (S1)” MedTech interviewed stated the AM staff called hospice on 12/19/22 due to a skin tear sustained during the 2AM fall. The skin tear is referenced in the hospice nurse’s notes from 12/19/22 and indicated the skin tear was 4cm x 2cm. The Facility Progress Notes do not indicate any skin tear for R1 on 12/19/22. There is a noted discrepancy between the Facility Progress Notes, and the hospice notes and MedTech interview which indicate a skin tear for 12/19/22. In addition, the facility did not submit an Incident Report to CCL for the unwitnessed fall and injury.
Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):
Exit interview conducted, copy of report and appeal rights emailed and printed.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2023
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 02/07/2023 06:00 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: GRANVIDA SENIOR LIVING AND MEMORY CARE
FACILITY NUMBER: 425802114

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/14/2023
Section Cited

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87211 (a)(1) Reporting Requirements (a) Each licensee shall... (1)A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below... This
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Administrator agreed to submit a statement of understanding of regulation 87211 and submit a plan to ensure incident reports are sent to CCl on time. Administrator agreed to submit plan to CCL by 2/14/23.
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requirement was not met as evidenced by: Based on record review, the licensee did not comply with the section cited above when the facility did not submit incident reports within 7 days, which posed a potential health and safety risk to residents in care.
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Type B
02/13/2023
Section Cited

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87211(a)(2) Reporting Requirements
(2) Occurrences, such as epidemic outbreaks, poisonings, catastrophes ...which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing
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Administrator agreed to submit a statement of understanding of regulation 87211 and submit a plan to ensure such occurrences such as COVID are reported within 24 hours. Administrator agreed to submit plan to CCL by 2/14/23.
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agency and to the local health officer when appropriate. This requirement was not met as evidenced by: Based on record review, the licensee did not comply with the section cited above when the facility did not report COVID in 24 hours, which posed a potential 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: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2023
LIC809 (FAS) - (06/04)
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