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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803301
Report Date: 02/05/2021
Date Signed: 02/09/2021 01:39:00 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/09/2020 and conducted by Evaluator Araceli Canela
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20200909125815
FACILITY NAME:GRANADA HILLS MANORFACILITY NUMBER:
486803301
ADMINISTRATOR:GUINTO, JOY J.FACILITY TYPE:
740
ADDRESS:1442 GRANADA STREETTELEPHONE:
(707) 651-9299
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:6CENSUS: 4DATE:
02/05/2021
UNANNOUNCEDTIME BEGAN:
05:01 PM
MET WITH:Dante GuintoTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Resident's medication is not properly stored.
Resident's needs are not being met.
Facility is unclean.
Food service is inadequate.
Resident is not provided with clean linens.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) A. Canela contacted Dante Guinto, Licensee/Administrator at Granada Hills Manor Facility by telephone on 2/5/2021 for the purpose of delivering findings on complaint investigation 21-AS-20200909125815. Due to COVID – 19 precautions a facility visit is not able to be conducted at this time.

LPA received statements, gathered records and conducted a physical visit of this facility on 12/9/2020 and made several observations. It was alleged Resident's medication is not properly stored, and medication for resident R1 is being left on the residents room accesible and not locked. R1 reported medication is to be provided every 4 hours and staff S1 does not want to wake up at night to provide the medication and will just leave the extra doze for R1 to take on their own. During the inspection of 12/9/2020 LPA observed a bottle of prescription medication and bottle of advil in R1's room, not locked. R1's Medical assesment from physician, states R1 may not handle their own medication or have access. LPA also observed a bottle of prescription ointment on R4's side table and a bottle of arthritis rub, not locked.
Continue report see LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 02/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2021
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 21-AS-20200909125815
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: GRANADA HILLS MANOR
FACILITY NUMBER: 486803301
VISIT DATE: 02/05/2021
NARRATIVE
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 It was also alleged resident's needs are not being met. During inspection LPA observed resident R5 seating on their wheelchair, watching television in the living room and R5 was only half dressed, R5 was wearing a shirt and an adult diaper with no pants and nothing to cover the lower body. Residents R6's hair was uncombed, and clothing showed several stains.

It was also alleged the home is unclean and the residents are not provided clean linens. During the inspection LPA observed the bathroom with stains on the floor and wall, LPA also observed the floor, walls and side tables in 2 of the 5 rooms. The sheets and pillow cases in R1 and R4's rooms were with stains.

It was also alleged food service is inadequate. During investigation LPA received several statements from 3 of 6 residents indicating they were not receiving fruits or vegetable or they were minimal. LPA also received a statement from staff S2 who indicated she provided a lot a cake to R6 for lunch and when questioned why would they just give cake, Staff S2 expressed that R6 was not offered spaghetti and meatballs or a sandwich like the other resident were provided because they ran out and could not offer it. On the inspection of 12/9/2020 LPA observed several chicken strip frozen entree from the brand Banquet. S2 stated R1 receives this because R1 likes chicken strips. R1's Physician report states R1 should have a special diet for weight management and the small banquet entree has 19grams of fat, high in sodium and carbohydrates and not appropriate for R1.

Based on the information received, the preponderance of evidence standard has been met, therefore all allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099-D. Appeal Rights were provided and signature on this report acknowledges receipt.

This report was emailed to facility to obtain signature.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 02/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/09/2020 and conducted by Evaluator Araceli Canela
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20200909125815

FACILITY NAME:GRANADA HILLS MANORFACILITY NUMBER:
486803301
ADMINISTRATOR:GUINTO, JOY J.FACILITY TYPE:
740
ADDRESS:1442 GRANADA STREETTELEPHONE:
(707) 651-9299
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:6CENSUS: 4DATE:
02/05/2021
UNANNOUNCEDTIME BEGAN:
05:01 PM
MET WITH:Dante GuintoTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Resident overdosed on medication.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) A. Canela contacted Dante Guinto, Licensee/Administrator at Granada Hills Manor Facility by telephone on 2/5/2021 for the purpose of delivering findings on complaint investigation 21-AS-20200909125815. Due to COVID – 19 precautions a facility visit is not able to be conducted at this time.
LPA received statements, gathered records and conducted a physical visit of this facility on 12/9/2020 and made several observations. It was alleged Resident overdosed on medication. LPA received statements and there was no documentation that resident had overdozed on medication. It was corroborated R1 did attempt to overdoze on medication in his previous home, a room and board. It was corroborated staff leave R1's medication for R1 to take, so that staff do not have to get up and provide at night. Staff stated they always provide the medication for R1 and deny R1 overdozinng.
The Department has investigated the above allegations and determined, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are Unsubstantiated.
This report was emailed to facility to obtain signature.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 02/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2021
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 6
Control Number 21-AS-20200909125815
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: GRANADA HILLS MANOR
FACILITY NUMBER: 486803301
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/06/2021
Section Cited
CCR
87465(h)(2)
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87465(h)(2) Incidental Medical and Dental Care (h) requirements shall apply to medications which are centrally stored: (2)Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other. This requirement was not met as evidenced by:
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Facility to send in written plan that will be followed.
POC Due date 2/6/2021
to LPA A. Canela
araceli.canela@dss.ca.gov
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LPA received statement from Ombudsman & VA caseworker of Medication bottles being left for R1. LPA observed on visit of 12/9 R1 had 2 bottles of medication accessible and not locked and R4 had an ointment and Arthritis rub. This is an immediate risk to the health and safety of residents in care.
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Type A
02/06/2021
Section Cited
CCR
87465(a)(5)
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87465(a)(5) Incidental Medical and Dental Care-(a) A plan for incidental medical & dental care shall be developed by each facility...obtaining such care, by compliance w/ the following: The licensee shall assist residents with self administered medications as needed.This requirement was not met, As evidenced
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Facility to send in written plan that will be followed.
POC Due date 2/6/2021
to LPA A. Canela
araceli.canela@dss.ca.gov
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by: R1 was provided his own bottle of medication to keep in his room. LPA observed medication accessible not locked & it was corroborated by outside sources, they have found R1 medication on R1's table & R1 states staff are not assisting him. This is an immediate risk to the health & safety of residents in care.
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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: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 02/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 21-AS-20200909125815
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: GRANADA HILLS MANOR
FACILITY NUMBER: 486803301
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/15/2021
Section Cited
CCR
87303(a)
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87303(a) Maintenance and Operation-The facility shall be clean, safe, sanitary & in good repair at all times..... This requirement was not met. As evidenced by: LPA observed bathrooms floors and 2 of 5 bedrooms not clean. This is a potential risk to resident s in care.
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Facility to send in written plan that will be followed.
POC Due date 2/15/2021
to LPA A. Canela
Type B
02/15/2021
Section Cited
CCR
87307(a)(3)(c)
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87307(a)(3)(c) Personal Accommodations & Services(a) Living accommodations & grounds shall-Equipment supplies necessary for personal care.(C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases.....This requirement was not met. As evidenced by: LPA observed 2 of 6 resident linens with stains, this is a potential risk to the residents in care.
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Facility to send in written plan that will be followed.
POC Due date 2/15/2021
to LPA A. Canela
araceli.canela@dss.ca.gov
Type B
02/15/2021
Section Cited
CCR
87555(b)(3)
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87555 General Food Service Requirements. (b) The following food service requirements shall apply:(3) Between-meal nourishment or snacks shall be made available for all residents unless limited by dietary restrictions prescribed by a physician.
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Facility to send in written plan that will be followed, plan for snacks being available for residents to take and/or staff providing snacks to residents
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This requireement was not met as evidenced by: LPA received corroborating statements from 4 of 6 residents, snacks are not being provided daily, LPA did not observe any snacks or fruits available for residents to take. This is a potential risk to residents in care.
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on a daily basis to residents & according to dietary restrictions
POC Due date 2/15/2021
to LPA A. Canela

araceli.canela@dss.ca.gov
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: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 02/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 21-AS-20200909125815
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: GRANADA HILLS MANOR
FACILITY NUMBER: 486803301
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/06/2021
Section Cited
HSC
1569.269(a)(6)
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§1569.269Enumerated rights; severability- (a) Residents of residential care facilities for the elderly shall have all of the following rights:(6) To care, supervision, & services that meet their individual needs & are delivered by staff that are sufficient in numbers,
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Facility to send in written plan that will be followed and proof of staff training in resident personal rights, residents care/needs & supervision
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qualifications,& competency to meet their needs. This requirement was not met. As evidenced by: LPA received corroborating statements from 3 of 6 residents, staff do not provide and/or provide minimal assistance to residents after dinner. On visit of 12/9 LPA observed R5 sitting in wheelchair in the living room wearing no pants. This is an immediate risk to the Health & safety of residents in care.
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POC Due date 2/6/2021
Proof of training by 2/12
to LPA A. Canela
araceli.canela@dss.ca.gov
Type A
02/06/2021
Section Cited
CCR
87555(a)
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87555(a) General Food Service Requirements(a) The total daily diet shall be of the quality & in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and
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Facility to send in written plan that will be followed regarding Reg 87555 General food service and facility plan to meet resident individual needs
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Nutrition Board....All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement was not met, As evidenced by: LPA received corroborating statements from 3 0f 6 residents, they are not being provided enough food, fruits/and or vegetable. LPA also received statement from staff S2, they provided cake to R6 for lunch because they ran out of the food they fed other residents. This is an immediate risk to residents in care.
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POC Due date 2/6/2021
to LPA A. Canela
araceli.canela@dss.ca.gov
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: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 02/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 6