425802114-5-18-2023-29-AS-KBUY-CSC4JA-20230530190825

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 425802114
Report Date: 05/18/2023
Date Signed: 05/18/2023 04:58:28 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
07/22/2021 and conducted by Evaluator Jeannette Olson

COMPLAINT CONTROL NUMBER: 29-AS-20210722151634

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: 41	DATE:	05/18/2023
		UNANNOUNCED	TIME BEGAN:	02:35 PM
MET WITH:	Eric Terrill, Administrator		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Facility staff does not adequately maintain residents' records.
Facility does not have adequate incontinent supplies.
Facility did not report incidents.

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 conducted the initial visit, requested relevant documents, interviewed reporting party, Administrator and care staff on 7/30/21. LPA Olson interviewed 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, ED and explained the purpose of the visit.

On the allegation: Facility staff does not adequately maintain resident’s records. It was alleged that the nurse left who had the sole responsibility of maintaining resident records and inputting information into the electronic record system (QMAR) and staff did not have access therefore could not do their job properly. Reporting Party reported there were charting errors in the QMAR. It was also reported that there was a new resident, Resident (R1), who had been at the facility for a few days but no one knew R1’s name, and there was no information or medication list for R1 in a binder or on the computer.
Contined 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: 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-20210722151634

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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Reporting Party said there was another resident who was at the facility for 3 weeks in July who had garbled speech but no one knew their name, and there was no DNR status or medication information for them. Administrator stated a new nurse started mid July 2021. The previous nurse quit in December 2020 and was on call from 5/2/21-7/5/21. LPA interviewed multiple staff who stated they could not access files, while one staff interviewed stated they never had issues. Staff stated there were internet issues at the facility, that affected the QMAR system. Staff stated management told staff to “deliver meds by heart”. Some staff would refuse to give medications unless there were printed records. LPA Olson visited the facility on 12/28/22 and when asked for records was told the network wasn’t working and was unable to access any records requested. LPA received the records a few days later. Based on staff interviews and LPA observation, facility records for residents were inaccessible on multiple occasions. Based on information obtained the allegation is Substantiated at this time.

On the allegation: Facility does not have adequate incontinent supplies. It was alleged that there are not enough pads, briefs or wipes for residents and staff sometime have to borrow supplies from others. Reporting Party states that there never enough supplies and the stock room is locked and only the Administrator has a key and that can be a problem if they’re not there. Interview with Administrator revealed they have been told that on occasion that there are no briefs. The supplies are kept in the basement, but staff do not have keys to the storage area. There were issues because staff ran out of supplies, but did not tell the manager before they left for the day. Administrator stated if supplies are needed, they are brought up when staff tell them the supply is low. Administrator stated the issue was caused by a communication breakdown. Staff interviewed revealed the lack of supplies comes up in daily manager meetings. Managers were responsible for ordering supplies but would tell the staff the families were bringing in the incontinence supplies. When staff spoke to the families, they discovered the families were being charged by the facility for the facility to provide the supplies. After staff brought this up to management, managers would say they’re on the way to bring the supplies but they never came. Some staff stated they did not have supplies often, and the staff in charge of placing orders often “forgot” to place them or were “lazy” and did not place on time. Staff stated sometimes the facility was totally out of their supply of incontinence supplies, and staff were told to go to CVS and buy supplies with their own money, and were sometimes reimbursed. Staff were also told to “borrow” supplies from residents whose families brought in supplies that the families paid for. Staff stated that later on, there was overstock supplies in the basement but staff did not have the keys to access the supplies. One staff interviewed stated they went to the facility in the middle of the night to unlock the basement supplies because there were no other supplies accessible to staff. Based on the information obtained, the allegation is Substantiated at this time. Continued on 9099-C (pg3)

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

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Control Number 29-AS-20210722151634

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 allegation: Facility did not report incidents. It was alleged that a resident was taken to the hospital on 7/20/21 and it was not reported. On 8/2/2021, CCL received three Serious Injury/Serious Illness reports as follows: 7-18-2021 9-1-1 was called for Resident 2 (R2) due to Resident was feeling weak and dizzy, and was having difficulty ambulating. Resident was Dx'd w/Urinary Tract Infection and later discharged from the hospital. Incident should have been reported to CCL no later than 7/25/2021. 7-20-2021 9-1-1 was called for Resident 3 (R3) who exhibited difficulty standing, lethargy, and a lack of appetite. Resident was Dx'd with a bladder infection and prescribed antibiotics. Incident should have been reported to CCL no later than 7/27/2021. 7-22-2021 9-1-1 was called by Resident 4 (R4) due a fall sustained. Resident was Dx'd with Urinary Tract Infection and transported to Samarkand (SNF). Incident should have been reported to CCL no later than 7/29/2021. LPA noted the incident reports were submitted after the initial complaint visit where the allegations were disclosed, and the incident reports were submitted late, after the required 7-day written notice. Based on information obtained the allegation is deemed Substantiated at this time. A Technical Violation will be issued today in lieu of a citation since the facility was cited for not reporting in a case management visit on 2/7/23.

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 Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (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-20210722151634

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 B 05/25/2023 Section Cited CCR 87506(a)	1 2 3 4 5 6 7	87506(a) Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement was not met as evidenced	1 2 3 4 5 6 7	Administrator agreed to submit a plan to CCL to ensure that resident records are readily available by 5/25/23.
	8 9 10 11 12 13 14	by: Based on interviews, the licensee did not comply with the above cited section when the facility did not have records readily available to facility staff and to licensing, which posed a potential health and safety risk for residents in care.	8 9 10 11 12 13 14
Type B 05/25/2023 Section Cited CCR 87307(a)(3)	1 2 3 4 5 6 7	87307(a)(3) Personal Accommodations and Services (a)...The following provisions shall apply: (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident....This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator agreed to submit a plan to CCL on how personal care products are readily available to CCL by 5/25/23.
	8 9 10 11 12 13 14	Based on interviews, the licensee did not comply with the above cited section when the facility did not have incontinent supplies readily available, which posed a potential health and safety risk for residents in care.	8 9 10 11 12 13 14

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: 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)

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