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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 475002785
Report Date: 08/07/2024
Date Signed: 08/07/2024 01:24:12 PM


Document Has Been Signed on 08/07/2024 01:24 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:GRENADA GARDENS SENIOR LIVING, LLCFACILITY NUMBER:
475002785
ADMINISTRATOR:BURSTEIN, NAFTALIFACILITY TYPE:
740
ADDRESS:424 HIGHWAY A-12TELEPHONE:
(530) 436-2514
CITY:GRENADASTATE: CAZIP CODE:
96038
CAPACITY:90CENSUS: 24DATE:
08/07/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Mike Burstein LicenseeTIME COMPLETED:
02:00 PM
NARRATIVE
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On 8-7-24 Licensing Program Analyst LPA Sarah Benson arrived at the facility unannounced to investigate and incident reported by Administrator Alma Peralta. LPA Benson met with Mike Burstein the Licensee. LPA Benson and Licensee Burstein toured the facility together.

LPA Benson interviewed 4 staff people and 1 resident. The following documents were received and reviewed: client and staff list with telephone numbers, employee work schedule, resident physician reports and resident care plan.


Based on interviews and record review, staff did not treat residents in care with dignity in their personal relationships with staff.



Exit interview conducted and copy of report and appeal rights were provided to the Licensee Mike Burstein.

See attached 809-D

SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Sarah BensonTELEPHONE: 530-895-5033
LICENSING EVALUATOR SIGNATURE:
DATE: 08/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 08/07/2024 01:24 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
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: 08/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/14/2024
Section Cited
CCR
87468.1(a)(1)

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Residents in All Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.This requirement is not met as evidenced by:
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Administrator will have training with staff concerning treating residents with dignity.
Administrator will train staff about residents personal rights.
Administrator will update care plan to monitor these behaviors and protect residents from these behaviors.
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Based on interviews staff member raised voice and used inappropriate words when addressing a resident in care.
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If necessary Licensee will increase staff to prevent behaviors.
Administrator will email LPA when complete.

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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: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Sarah BensonTELEPHONE: 530-895-5033
LICENSING EVALUATOR SIGNATURE:
DATE: 08/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2