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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 475002785
Report Date: 04/27/2023
Date Signed: 04/27/2023 09:55:52 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/05/2022 and conducted by Evaluator Rebecca Knight
COMPLAINT CONTROL NUMBER: 25-AS-20221205160138
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: 20DATE:
04/27/2023
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Julie Aguirre - Trainee DirectorTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Facility did not seek timely medical attention for injured resident - SUBSTANTIATED
Facility did not notify family that resident was injured - SUBSTANTIATED
INVESTIGATION FINDINGS:
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004/27/2023 9:30 AM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with Julie Aguirre trainee Director. The purpose of this visit was to deliver the results of a complaint investigation. Prior to initiating the visit, LPA self -screened for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility.

During the course of the investigation the administrator, and 5 staff were interviewed. LPA reviewed the following documents: related incident reports, Physician’s report, Admission Agreement, Care Plan, MAR, physicians orders, staff list with phone numbers.

Continued on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023
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 6
Control Number 25-AS-20221205160138
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME: GRENADA GARDENS SENIOR LIVING, LLC
FACILITY NUMBER: 475002785
VISIT DATE: 04/27/2023
NARRATIVE
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Page 1

Facility did not seek timely medical attention for injured resident - SUBSTANTIATED

Document review of R1’s Admission Agreement showed a date of admission of 11/18/2022.

3 of 5 staff stated that R1 had been diagnosed with a fractured wrist. 2 of 5 staff stated they did not know if R1 had a fractured wrist. 1 staff stated the injury was discovered on 11/26/2022, 2 staff stated the injury was discovered on 11/27/2022 but the swelling was “not that bad.” 3 staff stated they first saw that R1’s hand was swollen on 11/28/2022. 2 of 5 staff stated that R1 was taken to see a physician on 11/28/2022 when R1’s family showed up at the facility and transported R1 to the ER. 3 of 5 staff stated they did not know when the resident was taken to be seen by a physician.

The administrator stated On Sunday 11/27/2022 the med tech noticed that Resident 1 (R1) had a swollen wrist. They could not determine how R1 obtained the swollen wrist and were not sure if it was an injury or just swollen. Administrator stated that R1 was not complaining of pain and when asked R1 denied having pain. Administrator stated they figured since R1 didn’t have pain they would wait and see because the doctor was closed. When asked if they could have taken the resident to the ER to be examined on 11/27/2022 the administrator stated R1 was not complaining of pain so they did not take R1 to the ER.

It was determined that even though R1 was not complaining of pain they had swelling of the wrist and should have been taken to be examined by a medical professional as soon as the swelling was discovered. This allegation is substantiated.

Continued on LIC9099-C

SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 25-AS-20221205160138
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME: GRENADA GARDENS SENIOR LIVING, LLC
FACILITY NUMBER: 475002785
VISIT DATE: 04/27/2023
NARRATIVE
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Page 2

Facility did not notify family that resident was injured - SUBSTANTIATED

Document review of R1’s Admission Agreement showed a date of admission of 11/18/2022.

3 of 5 staff stated they did not know if the family was notified that R1 was injured. 1 of 5 staff stated on 11/28/2022 the family showed up at the facility and found out about the injury.

The administrator stated We found out on Sunday 11/27/2022 and we figured since R1 doesn’t have pain we would wait and see because the doctor was closed. Monday morning we were going to figure out what to do and that’s when R1’s daughter showed up and took R1 to the ER.

It was determined that the facility knew that R1 had a swollen wrist on 11/27/2022 but did not notify R1’s family that R1’s wrist was swollen. R1’s family found out that R1 had a swollen wrist when they arrived at the facility to visit R1 on 11/28/2022.This allegation is substantiated.

Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegations are 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 Naftali “Mike” Burstein.

Continued on LIC9099-D

SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 25-AS-20221205160138
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: GRENADA GARDENS SENIOR LIVING, LLC
FACILITY NUMBER: 475002785
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/11/2023
Section Cited
CCR
97465(a)
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87465(a) Incidental Medical and Dental. (a) A plan for incidental medical and dental care shall be developed by each facility. (2) The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation which may be limited to the nearest available medical or dental facility which will meet the resident's need. In providing transportation the licensee shall do so directly or make arrangements for this service. This requirement is not met as evidenced by:
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Licensee agrees to provide training for all direct care and administrative staff on the requirement to seek medical attention timely for residents. Licensee will schedule the training and provide CCL with the training content and signed staff attendance sheet as proof of correction.
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Based on interviews it was determined that the licensee did not seek medical attention timely for R1 when R1 presented with swelling of the wrist on 11/27/2022. This poses an immediate Health and Safety risk to residents in care.
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The proof of correction is to be received by LPA Knight by 5/11/2023.
Type B
05/11/2023
Section Cited
CCR
87466
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87466 Observation of the Resident - The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as … a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by:
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Administrator agrees to review regulation 87466 and submit a statement of understanding. Additionally, Administrator agrees to submit a plan of how facility staff will notify physician and responsible party of resident changes in a timely manner.
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Based on interviews it was determined that R1 presented with a swollen wrist and the licensee did not notify R1’s family. The family found out about the swelling in R1’s wrist when they arrived at the facility to visit R1. This poses a potential health and safety risk to residents in care.
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The proof of correction is to be received by LPA Knight by 5/11/2023.
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: Rebecca KnightTELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/05/2022 and conducted by Evaluator Rebecca Knight
COMPLAINT CONTROL NUMBER: 25-AS-20221205160138

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: DATE:
04/27/2023
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Mike Burstein - administratorTIME COMPLETED:
10:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility did not have a signed orders from physician or signed prescriptions on file for the resident - UNSUBSTANTIATED
INVESTIGATION FINDINGS:
1
2
3
4
5
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10
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13
004/27/2023 9:30 AM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with administrator Naftali “Mike” Burstein. The purpose of this visit was to deliver the results of a complaint investigation. Prior to initiating the visit, LPA self -screened for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 mask, gloves.
During the course of the investigation the administrator, and 5 staff were interviewed. LPA reviewed the following documents: related incident reports, Physician’s report, Admission Agreement, Care Plan, MAR, physicians orders, staff list with phone numbers.

Continued on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 25-AS-20221205160138
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME: GRENADA GARDENS SENIOR LIVING, LLC
FACILITY NUMBER: 475002785
VISIT DATE: 04/27/2023
NARRATIVE
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Page 3

Facility did not have a signed orders from physician or signed prescriptions on file for the resident - UNSUBSTANTIATED

Document review of Optum Rx Active Medication list dated 11/29/2022 includes list of medications that have been prescribed by R1’s physician. LIC602A Physician’s Report was signed by R1’s physician on 11/22/2022.

The administrator stated the Active Medication list generated by Optum Rx via R1’s physician serves as the signed prescriptions for R1.

It was determined that the Optum Rx Active Medication list is acceptable to serve as the physician’s order for R1’s medications. This allegation is unsubstantiated.

Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are UNSUBSTANTIATED.

An exit interview was conducted. A copy of the report was provided to facility administrator Naftali “Mike” Burstein.

SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6