475002785-10-11-2024-59-AS-KHOS-DA6S43-20241018133203

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 475002785
Report Date: 10/11/2024
Date Signed: 10/11/2024 01:54:04 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
06/25/2024 and conducted by Evaluator Sarah Benson

COMPLAINT CONTROL NUMBER: 59-AS-20240625100030

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:	10/11/2024
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Administrator Alma Peralta		TIME COMPLETED:	02:53 PM

ALLEGATION(S):

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Personal rights.

INVESTIGATION FINDINGS:

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On 10-11-24 Licensing Program Analyst LPA Sarah Benson arrived at the facility unanounced to deliver complaint finding. LPA Benson met with Administrator Alma Peralta and toured the facility together.

During the investigation of the complaint facility staff present on 06/07/2024 were interviewed and stated the resident was found down in the courtyard by staff who then alerted staff to call 911. Staff were unsure or inconsistent with the time the resident was last seen or the time the resident was found. The primary caretaker stated she clearly recalled last seeing the resident in the hallway by their room at/around 1330 hours when she first arrived to work, but then gave inconsistent statements that the client was found at 1430 hours and that 911 was called within 15 minutes of finding the resident.

Continue on 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: 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.

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20240625100030

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: 10/11/2024

NARRATIVE

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Document review revealed the 911 audio recorded call was obtained. Staff from the facility placed a 911 call on 06/07/2024 at 1554 hours and stated the resident had “just” had an un-witnessed fall outside and was still outside on the courtyard with two other staff. Staff advised the resident was not injured, did not need an ambulance and only needed help up. Fire personnel arrived and then requested an ambulance at 1621 hours.
Ambulance records obtained noted the resident “was outside since one this afternoon and was found a few hours later by Grenada Gardens staff lying on the ground with right hip pain and drenched in sweat.” It was reported the resident was found in a double brief that was soaked through. Staff admitted that residents had been double briefed due to staff being “lazy.”
Multiple other staff were interviewed and stated the resident was known to wander and wandered outside.
Staff reported, and documentary evidence confirmed the resident had an un-witnessed fall, at least once prior when he wandered outside. The facility owner and staff admitted that the facility outdoor area is not safe for residents who wander or elopement risks due to severe weather temperatures and the large size of the fenced outdoor area. The facility Director stated the exit doors are alarmed at night or during extreme weather. Other staff stated the doors are not alarmed during
the day at all. Weather data and multiple witness statements provided the outdoor temperature on 06/07/2024 reached the upper 90’s. The exit doors were not alarmed on 06/07/2024.Multiple witnesses, including facility, residents reported the facility is understaffed, resulting in staff being unable to attend to resident’s needs in a timely manner.

The residents examining Nurse Practitioner (NP), as well as his treating nurse were interviewed. The medical staff stated the resident was “hot and sweaty,” and had significant edematous (swelling) of his face and eyelids, indicating the resident was laying prone (face down), “for hours.” The medical staff could not conclusively say the residents heart attack (non-ST-elevation myocardial infarction – NSTEMI) was a result of a preexisting cardiac issue or from the stress of the incident. Medical staff stated, the resident had detrimental medical issues from being outside too long.”
As a result of the resident’s injury and the facility’s failure to met the residents basic service needs 87464 Section 87101(c)(3) and Health and Safety Code section 1569.2(c). The violation warrants an immediate civil penalty in the amount of $500, which is being issued today. At this time, the issuance of an additional civil penalty is still being determined and the Administrator has been informed that an additional civil penalty may be assessed, at a later date, based on Health and Safety Code §1569.49.

Exit interview conducted. A copy of the report has been issued. Appeal Rights provided. Signature on this report acknowledges receipt of these reports. See 9099-D and LIC421IM.

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Sarah Benson	TELEPHONE: 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: 10/09/2024

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20240625100030

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: 10/11/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/20/2024 Section Cited CCR 87464	1 2 3 4 5 6 7	Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). Failure to provide the care and supervision for a resident. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee agrees to will outline the makeup of the residents in care. Will create an outline of resident’s level of care. Create a list of care staff duties. Licensee will send an updated staffing plan showing that staffing is adequate to meet residents’ needs.
	8 9 10 11 12 13 14	Based on interviews and records review, the licensee failed to ensure that the basic needs of the residents in care were met. As a result, R1 eloped from the facility and was found outside on the ground for an extended perior of time. R1 was transported to ER for hospitalization. This poses an immediate health, welfare and safety hazard to residents in care.	8 9 10 11 12 13 14	Proof of correction to be submitted to LPA by 11-20-24
	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: 10/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024

LIC9099 (FAS) - (06/04)

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