475002785-12-2-2024-59-AS-KHOS-DBSQLP-20241209111616

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 475002785
Report Date: 12/02/2024
Date Signed: 12/02/2024 04:05:59 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
07/17/2024 and conducted by Evaluator Sarah Benson

COMPLAINT CONTROL NUMBER: 59-AS-20240717144013

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: 19	DATE:	12/02/2024
		UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Alma Peralta Administrator		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Medication management.

INVESTIGATION FINDINGS:

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On 12-2-24, Sarah Benson, Licensing Program Analyst (LPA) arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 08/23/24. LPA Benson met with Alma Peralta Administrator and explained the purpose of the visit.

During the interview process, 2 staff persons were interviewed. The following documents were received and reviewed: incident reports, physician’s report, client files, Care Plan, MAR, physicians’ orders, staff list with phone numbers and work schedule, any observation records.

Continued on substantiated 9099-C and 9099-D

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: 12/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2024

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

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
07/17/2024 and conducted by Evaluator Sarah Benson

COMPLAINT CONTROL NUMBER: 59-AS-20240717144013

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: 19	DATE:	12/02/2024
		UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Alma Peralta Administrator		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Facility staff do not ensure signal system is accessible to residents.

INVESTIGATION FINDINGS:

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During the interview process, 2 staff persons were interviewed. The following documents were received and reviewed: Client and staff list with telephone numbers, employee work schedule and observation logs.
During staff interviews, staff reported each client has a pull cord at bedside and in each bathroom. Staff reported the more alert residents can have a device on their walkers also. Staff stated the less active/alert residents have the alert cord attached to a stuffed animal making it easier access to pull the cord.
Based on investigation, LPA Benson observed each resident room has a pull cord on the wall by resident bed and one in each resident bathroom. LPA Benson observed a resident with a pull cord attached to a stuffed animal for easier access to pull the cord. LPA Benson observed a resident with a call button on their walker. LPA Benson pulled the cord in a resident room and staff responded within minutes.
Based on the investigation, observations and interviews conducted the allegation is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated.

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: 12/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 59-AS-20240717144013

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: 12/02/2024

NARRATIVE

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Document review revealed, residents are not receiving prescribed medications as medication logs were not signed as given on 7-15-24, for residents R1 and R2 for multiple medications. During Staff interviews staff reported the med. tech on duty didn’t get around to signing the MAR after giving the medication on 7-15-24 but has been signed at this time.

LPA Benson discovered during document review R1 was out of pain medication from 7-1-24 through 7-3-24 and it was recorded the resident has been taking the pain medication daily. It was reported the resident visited the E.R. at 12:45 PM on 7-3-24 due to extreme pain.

It was discovered the pain medication prescription is written as twice a day as needed for pain. The MAR for June of 2024 recorded the pain medication with three open slots AM, noon, PM, PRN. On 7-17-24 the MAR is initialed three times a day AM, noon, PM. Staff reported on my copy 7-17-24 the third entry is circled as not given. On LPA Bensons copy of the MAR none of the three initialed does are circled. During record review the resident had been given a pain medication ordered as twice a day PRN pain but recorded as administered by staff three times a day on 7-17-24.

During document review it was discovered that R1’s Cymbalta was not administered from 6-27-24 to 7-17-24. Staff reported R1’s Cymbalta ran out and the primary care physician moved. Staff reported they were unable to get a refill for the Cymbalta.

A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, as the licensee shall assist residents with self-administered medications as needed.

The residents have missed medication due to lack of timely refills by staff. The facility staff are not keeping an accurate record of doses of medication which are centrally stored and maintained by the facility.

Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D.

Appeal rights were provided. An exit interview was conducted. A copy of the report was provided to Alma Peralta Administrator.

Continued on LIC9099-D

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Sarah Benson	TELEPHONE: 530-895-5033
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 4

Control Number 59-AS-20240717144013

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: 12/02/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/02/2025 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	A plan for incidental medical ... The plan shall encourage routine medical ... and provide for assistance in obtaining such care, by compliance with the following:The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee agrees to have a pharmacy training. Administrator will transition into e-mar. Administrator will do a weekly audit.
	8 9 10 11 12 13 14	Based on interviews and records review, :The licensee did not assist residents with self-administered medications as needed. The staff are not keeping an accurate record of mediation administration. This poses an immediate health, welfare and safety hazard to residents in care.	8 9 10 11 12 13 14
	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: 12/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4