425802114-2-7-2023-29-AS-KBUY-CP5S6R-20230217123623

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 425802114
Report Date: 02/07/2023
Date Signed: 02/07/2023 06:02:05 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/28/2022 and conducted by Evaluator Jeannette Olson

COMPLAINT CONTROL NUMBER: 29-AS-20220428135036

FACILITY NAME:	GRANVIDA SENIOR LIVING AND MEMORY CARE		FACILITY NUMBER:	425802114
ADMINISTRATOR:	KAWANA ANTHONY		FACILITY TYPE:	740
ADDRESS:	5464 CARPINTERIA AVE		TELEPHONE:	(805) 566-0017
CITY:	CARPINTERIA	STATE: CA	ZIP CODE:	93013
CAPACITY:	83	CENSUS: 50	DATE:	02/07/2023
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Ted Burgess, Executive Director and Ashley Nash, Business Office Director		TIME COMPLETED:	06:20 PM

ALLEGATION(S):

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Facility is not following COVID protocols.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Olson and Phillips conducted an unannounced follow up complaint visit to issue final findings. LPAs met with Ted Burgess, Executive Director and Ashley Nash, Business Office Director and explained the purpose of the visit.

On the allegation: Facility is not following COVID protocols. It was alleged that a visitor (V1) went to the facility to see Resident 1 (R1) on 4/27/22 and there were no signs or notification of a COVID-19 outbreak. Interviews revealed the visitor received an email on 4/28/22 that there was a positive case in the facility on 4/25/22 and there were 10 total positive cases. LPA Kontilis interviewed V1 who stated on their way out, they talked to the Administrator Kawana Anthony who apologized and said there should have been a sign up and all visitors should have been informed that there was a COVID positive case in the facility. V1, who is R1’s conservator, also stated they were not notified that R1 tested positive for COVID on 4/25/22. V1 stated they found a note in R1’s room saying “you need to isolate”.
Continued on 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20220428135036

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 02/07/2023

NARRATIVE

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PIN 22-07-ASC indicated for visitors of residents in isolation, the licensee should provide and require the visitor wear PPE recommended for facility staff as specified in PIN 21-12-ASC. A visitor of a resident under isolation does not need N95 respirator fit testing but should be instructed on how to perform a seal check. PIN 20-13-ASC states: Upon confirmation that a person in care or facility staff member has tested positive for COVID-19, and either remains in the facility or is no longer in the facility, CCLD advises ASC licensees to provide immediate notice to families of all persons in care.

LPA Olson observed that CCL was notified on 4/26/22 that R1 tested positive for COVID on 4/25/22 along with 9 other residents and a staff. LPA Olson observed CCL did not receive an incident report for any of these residents testing positive for COVID-19 and will be cited in a Case Management. Based on interviews and record review the allegation: Facility is not following COVID protocols is substantiated.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D):

Exit interview conducted, copy of report and appeal rights were emailed and printed..

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20220428135036

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 CCR 87468.1(a)(2)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirment was not met as	1 2 3 4 5 6 7	Administrator agreed to submit a statement of understanding of CCL PINs and submit to CCL by 2/14/23.
	8 9 10 11 12 13 14	evidenced by: Based on interviews, the licensee did not comply with the section cited above when the facility did not inform visitors of the COVID outbreak and did not inform responsible parties immediately about positive results, which posed a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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