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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425802114
Report Date: 05/18/2023
Date Signed: 05/18/2023 04:54:36 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
09/08/2021 and conducted by Evaluator Jeannette Olson
COMPLAINT CONTROL NUMBER: 29-AS-20210908140337
FACILITY NAME:GRANVIDA SENIOR LIVING AND MEMORY CAREFACILITY NUMBER:
425802114
ADMINISTRATOR:KAWANA ANTHONYFACILITY TYPE:
740
ADDRESS:5464 CARPINTERIA AVETELEPHONE:
(805) 566-0017
CITY:CARPINTERIASTATE: CAZIP CODE:
93013
CAPACITY:83CENSUS: 41DATE:
05/18/2023
UNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Eric Terrell, AdministratorTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Facility did not provide resident timely medical attention.
Facility did not recognize resident's change of condition.
Facility staff did not report incident(s) to resident's responsible party.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Olson conducted an unannounced subsequent complaint visit to issue final findings on the allegations above. LPA Kontilis interviewed reporting party on 9/9/21, conducted the 10 day visit and requested relevant documents on 9/17/21. LPA Olson interviewed POA on 5/12/23 and staff who worked at the facility during the time of this complaint on 5/9/23 and 5/12/23. LPA Olson met with Eric Terrill and explained the purpose of the visit.

Resident 1 (R1) was admitted to the facility on 4/5/21. R1’s 3/29/21 Pre Placement Appraisal states R1 is Nonablulatory, has limited right hand strength, a bad right knee, Dementia and was hospitalized June 2020 for a UTI. R1 is not able to walk without physical assistance, unable to follow signs and instructions, uses a wheel chair and needs help transitioning in and out of bed as well as dressing, bathing and hygiene. R1 requires monitoring while eating and needs food cut up into bite size pieces. R1’s Physician’s Report dated 3/22/21 lists R1’s Primary Diagnosis is Dementia and Secondary Diagnosis is Hypothyroidism.
Continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023
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 4
Control Number 29-AS-20210908140337
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: 05/18/2023
NARRATIVE
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Under ‘Physical Health Status’, ‘special diet’ is selected and “unable to cut own food or open juice boxes” is selected.
Interim Service Plan dated 4/10/21 states a fall-without obvious injury occurred around 5:30 pm in R1’s room and resident was trying to sit on wheelchair. Service Plan indicates staff should monitor for any bruising and staff signed off: “I have been made aware of the above resident rare needs and will follow the service plan approaches outlined above.”

Facility charting notes state on 4/10/21 at 10:17 pm resident was found on the floor by closet door. Resident stated they were trying to get in wheelchair and slipped. Resident had no injuries. Residential Care Coordinator and Administrator were notified. On 5/15/21 at 1:59 am Resident was found on the ground by the bed. Resident reported no pain. Resident explained they were trying to help a dead man on the floor. Resident insisted a man was on the floor and we needed to assist him. There was no resident there. Residential Care Coordinator and Administrator were notified. On 5/16/23 “Resident found sitting next to bed states ‘John she needed to move over for’ continued to speak of John being in the bed and having to be on the floor. Vitals done and resident reports no pain on buttocks or rest of the body. ED, RCC and [POA] aware.”

On 5/18/21 at 11:12 “Approximately 10:45 am resident was sent out to cottage hospital via ambulance, due to low O2 POA…was notify. Note: resident looked to be doing well early morning, caregiver showered (R1) and took (R1) AL dinging room for Breakfast, (R1) ate…breakfast and staying in dining room…talking and interacting with other residents. Caregiver escorted resident back to…apartment and appeared to be doing well later caregiver was doing…rounds and notice that (R1) looked a bit different no being…self and not that alert and awake as usual. Caregiver immediately notify MT& RCC Vitals were taken, resident had low o2 vitals were as fallow: bp: 94/77 P84 Body temperature 95.8 O2= 71. 911 was called immediately when AMR arrived…residents O2 was 57.”

5/19/21 8:50 am Staff communicated with POA with an update: “Resident is in ICU (R1) is not breathing well, has a UTI and hospital thinks (R1) might have aspirated on food or saliva.”

Facility fax dated 5/18/21: Facility faxed R1’s doctor on 5/20/21 at 2pm: R1 “was sent out to Cottage Hospital in Santa Barbara, unusual sudden change in condition. Low 02 94/77 P84 Temp 95.8 O2=72. Sent out to Cottage Hospital 5/18/21 @ 10:45 am via ambulance (family) was notify” There was also a note “Acknowledged RPonce MD on Call 5/20/21.” Continued on 9099-C (Pg 3)
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 29-AS-20210908140337
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: 05/18/2023
NARRATIVE
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On the allegations: Facility did not provide resident timely medical attention and Facility did not recognize resident's change of condition. It was alleged that Resident 1 (R1) was sent to the hospital on 5/18/21 and passed away on 5/22/21 of Sepsis and aspirated respiratory failure. Reporting Party (RP) stated the at the hospital R1 was diagnosed with a UTI and the doctor stated it could have been identified sooner if staff were trained in warning signs. Reporting party also alleges that R1 was declining and hallucinating, but staff did not communicate or notify R1’s physician about the changes. LPA reviewed facility records that do not indicate that the facility contacted R1’s doctor or tested for a UTI on 5/15/21 or 5/16/21 when staff found R1 on the floor hallucinating. It wasn’t until 5/18/21 that R1 was sent to the hospital due to not being alert. Staff interviewed stated they remembered this resident and in May 2021 they started screaming in the hallways and acting strange. LPA Olson interviewed staff who stated that falls, being found on the floor and hallucinations were classic signs of UTIs. Staff also stated the facility management was “disorganized” and remembers every manager saying to tell someone else, because it’s not their job or say they would call the doctor/family in the morning but they never did. The facility should have recognized R1’s change in condition on 5/15/21 and 5/16/21 when they started hallucinating and sought medical attention. Based on the information obtained the allegations are deemed Substantiated at this time.

On the allegation: Facility staff did not report incident(s) to resident's responsible party. It was alleged that the facility notified family of the incidents but not the POA. LPA observed facility charting notes that state after the 5/15/21 fall only Resident Care Coordination and Administrator/Executive Director were notified. On 5/16/21 notes indicate the POA was notified of the incident as well as on 5/18/21 when R1 went to the hospital. LPA interviewed POA who stated there were not notified of any falls/hallucinations R1 had and stated the facility seemed very disorganized and there was confusion about who did what, and they never contacted them about anything. POA stated they found out R1 was in the hospital by a family member who the facility called. This family member lives in Colorado, when the POA lived near the facility. Staff interviewed stated they found R1 on the floor a few times on their NOC shift but were told management would call the Responsible Party the next day because it was late. Staff interviewed stated they believed the managers would often forget and not call family for basic incidents or hospitalizations. Based on the information obtained, the allegation: Facility staff did not report incident(s) to resident's responsible party is Substantiated.

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: 05/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 29-AS-20210908140337
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: 05/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/25/2023
Section Cited
CCR
87465(a)(1)
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87465(a)(1) Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed....(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by:
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Administrator agreed schedule a training on the facilities Incidental Medical and Dental Care plan on 5/25/23 and to send training reccords to CCL with name, date, topic covered and signiture.
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Based on interviews and record review, the licensee did not comply with the above cited section when the facility did not seek medical attention for R1 or contact R1’s physician after R1 hallucinated, which posed an immediate health and safety risk for residents in care.
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Type B
05/25/2023
Section Cited
CCR
87211(a)(1)
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87211 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports...(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...(D) Any incident which threatens
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Administrator agreed to submit a plan to licensing to ensure reporting requirements are met and submit to CCL by 5/25/23
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the welfare, safety or health of any resident... This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not comply with the above cited section when the facility did not notify R1’s POA of incidents, which posed a potential health and safety risk for residents.
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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: 05/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4