486803301-10-20-2021-21-AS-KMOA-C9C2TL-20211202164054

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803301
Report Date: 10/19/2021
Date Signed: 10/20/2021 11:27:20 AM

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
10/14/2021 and conducted by Evaluator Araceli Canela

COMPLAINT CONTROL NUMBER: 21-AS-20211014140951

FACILITY NAME:	GRANADA HILLS MANOR		FACILITY NUMBER:	486803301
ADMINISTRATOR:	GUINTO, JOY J.		FACILITY TYPE:	740
ADDRESS:	1442 GRANADA STREET		TELEPHONE:	(707) 651-9299
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94591
CAPACITY:	6	CENSUS: 5	DATE:	10/19/2021
		UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Dante Guinto		TIME COMPLETED:	01:43 PM

ALLEGATION(S):

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Residents room is malodorous
Staff are not providing adequate food service

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), A. Canela arrived unannounced, for the purpose of opening a complaint investigation, regarding the above listed allegations. LPA toured the facility prior to Administrator, Dante Guinto's arrival, made observations and gathered statements.

LPA obtained and reviewed records, conducted interviews, toured all resident bedrooms, and outside of the home. It was alleged residents room is malodorous. LPA spoke to residents in their bedrooms and found 4 out of the 5 bedrooms to have urine smell; 2 of those bedrooms had a strong smell of urine an one of them being so strong LPA was unable to stay in the room due to the strong odor. LPA toured the facility at 9:45 AM and several times during the visit; at 1:20 PM, LPA requested facility to empty resident R3's bedside commode, as it still contained the same urine from when LPA observed earlier in the morning and R1's plastic urinal as it still contained urine from earlier that morning too.
Continue report see LIC9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2021

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 21-AS-20211014140951

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: 10/19/2021

NARRATIVE

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It was also alleged, staff are not providing adequate food service and food is inadequate, lacking variety, not enough and of poor quality. LPA took statements, reviewing documents and menus; inspecting the kitchen and food supplies. LPA observed the main refrigerator practically empty, the facility has 2 additional refrigerators in the garage, one which they say is for staff and an additional for residents. LPA found that the refrigerator in the garage that is said to be used for residents food had plastic cake containers that were reused and now contained cooked brocoli, and small tied up grocery bags with other vegetables, many of the food was not labeled, not in the original container or containers were open, not covered or food appeared to have heavy frost bite. One plastic bowl in the freezer had spaghetti and it was observed with a small plate just over the container to cover it. When Administrator, Dante showed up to the facility, he came in with prepared food items and some fresh fruit. The facility was observed not to have any fresh fruit and the only fresh vegetable were a few heads of lettuce, in which some appeared to be starting to go bad. Administrator expressed that the facility does the food shopping on Wednesdays and that is why they were short on food. LPA requested to see the menu plan and the facility is not following their Menu plan.
The refrigerator in the garage that is used for the staff was observed packed with food and fresh cantaloupe, items in refrigerator are also not properly stored and are accessible to residents. In addition LPA received corroborating statements expressing the facility is not providing enough food or lack of snacks between meals. It was also disclosed to LPA, that because LPA and Administrator were at the facility they were provided with
better food for today, but it is not always like this. There is usually not enough food being served, or fruit and vegetables.
Based on LPA’s observations of food items available in the facility and statements received, the preponderance of evidence standard has been met, therefore the allegations for residents room is malodorous and staff are not providing adequate food service are both found to be SUBSTANTIATED.

The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights and this report will be emailed to facility due to printer problems.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2021

LIC9099 (FAS) - (06/04)

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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
10/14/2021 and conducted by Evaluator Araceli Canela

COMPLAINT CONTROL NUMBER: 21-AS-20211014140951

FACILITY NAME:	GRANADA HILLS MANOR		FACILITY NUMBER:	486803301
ADMINISTRATOR:	GUINTO, JOY J.		FACILITY TYPE:	740
ADDRESS:	1442 GRANADA STREET		TELEPHONE:	(707) 651-9299
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94591
CAPACITY:	6	CENSUS: 5	DATE:	10/19/2021
		UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Dante Guinto		TIME COMPLETED:	01:43 PM

ALLEGATION(S):

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Resident has lost a significant amount of weight while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), A. Canela arrived unannounced, for the purpose of opening a complaint investigation, regarding the above listed allegations. LPA toured the facility prior to Administrator, Dante Guinto's arrival, made observations and gathered statements.
LPA obtained and reviewed records, conducted interviews, toured all resident bedrooms, and outside of the home. It was alleged resident has lost a significant amount of weight while in care and that resident (R1) was about 250lbs when R1 moved in to the facility and now appeared to have lost a lot of weight and was now weighing about 125lbs.
LPA reviewed resident R1's file and recent Physician report LIC602 dated 9/29/2021 in which R1's weight was recorded at 170 lbs. Previous LIC602, dated 11/9/2018 showed R1's weight at 190 lbs. LPA spoke with R1 who expressed they felt like they had lost some weight, but not a lot. LPA did not receive any additional information or medical documentation to

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2021

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

LIC9099 (FAS) - (06/04)

Page: 4 of 4

Control Number 21-AS-20211014140951

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: 10/19/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/21/2021 Section Cited CCR 87555(b)(9)	1 2 3 4 5 6 7	87555(b)(9)General Food Service Requirements. (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. ***Based upon statements and observations, this requirement has not been met as evidenced by:	1 2 3 4 5 6 7	Administrator agrees to submit in writing a plan to oversee food service which details activities such as menu planning, following menu planned, staff training regarding food preparation and storage. Plan to be submitted to CCL by POC date10/21/2021 in order to clear the deficiency.
	8 9 10 11 12 13 14	During today's visit and facility physical inspection of refrigerators. LPA observed majority of food items in the refrigerator and freezer were not properly stored. prepared or left over food is stored in containers not approved for freezer preservation, broken or not closed or labeled containers food showed frost. This is an immediate risk to the health & safety of residents in care.	8 9 10 11 12 13 14	To LPA A. Canela
Type B 10/21/2021 Section Cited CCR 87625(b)(3)	1 2 3 4 5 6 7	87625(b)(3)Managed Incontinence (b) in addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following:(3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.	1 2 3 4 5 6 7	Facility to send in written plan of action , that will be followed to ensure rooms are free of odors and residents are assisted and remain clean and dry. POC due date 10/21/2021
	8 9 10 11 12 13 14	This requirement was not met as evidenced by. During today's inspection LPA found room #2-#5 with urine odor, room #3 had strong odor that prevented LPA from remaining in the room. At 1;20 LPA requested facility to empty the porta potty in room 5 and urine on plastic urinal in room 4 as staff had still not removed it since LPAs arrival in the AM. This is an immediate danger to the health and safety of residents in care.	8 9 10 11 12 13 14	To LPA A. Canela

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: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2021

LIC9099 (FAS) - (06/04)

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