475002785-12-7-2023-59-AS-KHOS-D39GRH-20240311053423

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 475002785
Report Date: 12/07/2023
Date Signed: 12/07/2023 03:40:25 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/11/2023 and conducted by Evaluator Sarah Benson

PUBLIC

COMPLAINT CONTROL NUMBER: 59-AS-20230711093918

FACILITY NAME:	GRENADA GARDENS SENIOR LIVING, LLC		FACILITY NUMBER:	475002785
ADMINISTRATOR:	BURSTEIN, NAFTALI		FACILITY TYPE:	740
ADDRESS:	424 HIGHWAY A-12		TELEPHONE:	(530) 436-2514
CITY:	GRENADA	STATE: CA	ZIP CODE:	96038
CAPACITY:	90	CENSUS: 21	DATE:	12/07/2023
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Administrator Alma P		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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9

Staff working without a fingerprint clearance.

INVESTIGATION FINDINGS:

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On 12-07-23,at 12:30PM Sarah Benson, Licensing Program Analyst (LPA) arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 07/11/23. LPA Benson met with Administrator Alma Peralta, and explained the purpose of the visit.

Staff working without fingerprint clearance.
During the interview process 6 staff people were interviewed. The following documents were received and reviewed: Client and staff list with telephone numbers, employee work schedule, resident physician reports, skilled nursing visits, hospice services initiation, resident care agreement, facility fire clearance and guardian background check system.

Continued 9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Sarah Benson	TELEPHONE: 530-895-5033
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023

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 5

Control Number 59-AS-20230711093918

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GRENADA GARDENS SENIOR LIVING, LLC	FACILITY NUMBER: 475002785
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/07/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 12/17/2023 Section Cited CCR 87355(e)	1 2 3 4 5 6 7	Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: This requirement is not met as evidenced by:	1 2 3 4 5 6 7	All staff shall be criminally cleared prior to working in the facility. Civil penalties shall be issued for this deficiency
	8 9 10 11 12 13 14	Based on investigation and interviews a staff member was working at the facility before having fingerpring clearance.	8 9 10 11 12 13 14	Staff member's last day of work Deficiency cleared.
	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: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Sarah Benson	TELEPHONE: 530-895-5033
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 59-AS-20230711093918

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GRENADA GARDENS SENIOR LIVING, LLC	FACILITY NUMBER: 475002785
	VISIT DATE: 12/07/2023

NARRATIVE

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Staff working without fingerprint clearance.

During the investigation process, LPA reviewed guardian background check discovering that staff 6 had an incomplete application. On 7-11-23 during interviews, the Administrator Alma Peralta stated that the Ombudsman was at the facility recently and notified the administrator that staff 6 had no background clearance. The Administrator Alma Peralta stated staff 6 was not associated with the facility. On 10-26-23 during LPA's interview staff 6 stated, I had my fingerprints done but I never got the results back. Staff 6 stated I am applying for an exemption so I can go back to work.

Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview was conducted and the report was provided to Administrator Alma Peralta.

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Sarah Benson	TELEPHONE: 530-895-5033
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023

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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/11/2023 and conducted by Evaluator Sarah Benson

PUBLIC

COMPLAINT CONTROL NUMBER: 59-AS-20230711093918

FACILITY NAME:	GRENADA GARDENS SENIOR LIVING, LLC		FACILITY NUMBER:	475002785
ADMINISTRATOR:	BURSTEIN, NAFTALI		FACILITY TYPE:	740
ADDRESS:	424 HIGHWAY A-12		TELEPHONE:	(530) 436-2514
CITY:	GRENADA	STATE: CA	ZIP CODE:	96038
CAPACITY:	90	CENSUS: 21	DATE:	12/07/2023
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Administrator Alma P		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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9

Facility violating fire clearance.
Staff provide care to residents while under the influence of marijuana.
Water temperature exceeds required limit.

INVESTIGATION FINDINGS:

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13

On 12-07-23 at 12:30PM Sarah Benson, Licensing Program Analyst (LPA) arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 07/11/23. LPA Benson met with Administrator Alma Peralta, and explained the purpose of the visit. LPA and Administrator toured the facility together inspecting dinning area, common areas and two resident rooms. During todays visit LPA test water During LPA's visit the water temperature testeed at 114.3 degree Fahrenheit.

During the interview process 6 staff people were interviewed. The following documents were received and reviewed: Client and staff list with telephone numbers, employee work schedule, resident physician reports, skilled nursing visits, hospice services initiation, resident care agreement, facility fire clearance and guardian background check system.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Sarah Benson	TELEPHONE: 530-895-5033
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023

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 59-AS-20230711093918

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GRENADA GARDENS SENIOR LIVING, LLC	FACILITY NUMBER: 475002785
	VISIT DATE: 12/07/2023

NARRATIVE

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Facility violating fire clearance.

During the investigation process, the facility records indicate Grenada Gardens is approved for 10 Hospice residents. The facility has a Hospice Wavier on file therefore can accept bedridden Hospice residents.

Although the above allegations mentioned may have happened, or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are unsubstantiated.

Staff provide care to residents while under the influence of marijuana.

During the staff interview process, the overwhelming response from staff members was no, staff do not smoke marijuana at work.

Although the above allegations mentioned may have happened, or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are unsubstantiated.

Water temperature exceeds the required limit.

It was reported a resident burned hands with hot water from a faucet at Grenada Gardens.

On 07-20-23 during investigation, LPA tested and recorded the water temperature at 114-degree Fahrenheit, in two separate resident rooms. The water temperature tested in the required temperature range of 105 f to 120 f. During interviews it was reported by staff that the top of a resident’s hands are red and the redness would return from time to time. Two staff members stated the resident returned from a family day visit with the top of her hands red. On 07-20-23 during LPA’s interview, Administrator Alma Peralta stated the hospice nurse examined residents hands and couldn’t confirm it was a burn. LPA was unable to interview resident as they moved to another facility.

When LPA reviewed Hospice nursing notes dated 06-17-23 it was reported by nurse, the redness and chapped appearance of residents hands may not be from hot water.

Although the above allegations mentioned may have happened, or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are unsubstantiated.

A copy of the report was given to Administrator Alma Peralta.

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Sarah Benson	TELEPHONE: 530-895-5033
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 5