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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 475002785
Report Date: 10/11/2024
Date Signed: 10/11/2024 01:31:34 PM


Document Has Been Signed on 10/11/2024 01:31 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: 21DATE:
10/11/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Administrator Alma PeraltaTIME COMPLETED:
01:30 PM
NARRATIVE
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On 10-11-24 Licensing Program Analyst LPA Sarah Benson arrived at the facility and met with Administrator Alma Peralta to discuss concerns at the facility.

Based on interviews and records review the department has determined the facility dose not have enough staff to met the resident needs. An incident happened on 6-7-24 that reflect there is not enough staff to provide the services necessary to meet resident needs. It has been reported by the administrator and care staff the facility has one direct care staff for twenty resident with varying needs.

The following Deficiency has been sited.

See attached 809-D.







Exit interview conducted. A copy of the report has been issued. Appeal Rights provided. Signature on this report acknowledges receipt of these reports.
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Sarah BensonTELEPHONE: 530-895-5033
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2024
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 10/11/2024 01:31 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: 10/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/11/2024
Section Cited
CCR
87411(a)

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) Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by records and statements that found insufficient staff to meet resident needs. This posed an immediate risk to residents.
This requirement is not met as evidenced by:
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Licensee agrees to increase staffing levels to meet resident’s needs and to provide adequate supervision to residents in care. The licensee shall conduct a staff training concerning the importance of monitoring the residents, performing resident counts to ensure residents do not elope from the facility.
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Based on interviews and records review, the licensee failed to ensure that there were sufficient staff present to provide supervision to residents to ensure that no residents eloped from the facility. As a result, R1 eloped from the facility and was found outside on the ground for an extended perior of time. 911 was called. R1 was transported to ER for hospitalization. This poses an immediate health, welfare and safety hazard to residents in care.
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Proof of correction to be submitted to LPA by 11-11-24. Licensee will submit a statement that the staffing configuration discussed today will be maintained until the facility completes a comprehensive analysis to develop staffing needs.
Staff sign sheets for all related trainings and updated staffing plan showing increased staffing. The facility formula for determining staffing needs changes in the existing plan of operations, tha changes will be submitted to CCL for approval.

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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: 10/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2