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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 577000418
Report Date: 01/06/2023
Date Signed: 01/06/2023 01:56:57 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/04/2022 and conducted by Evaluator Jill Nakagawa
COMPLAINT CONTROL NUMBER: 21-AS-20221004190046
FACILITY NAME:GRAND RIVER CARE CENTER-WESTFACILITY NUMBER:
577000418
ADMINISTRATOR:PAZ, DIANAFACILITY TYPE:
740
ADDRESS:509 MICHIGAN BOULEVARDTELEPHONE:
(916) 373-1591
CITY:WEST SACRAMENTOSTATE: CAZIP CODE:
95691
CAPACITY:30CENSUS: DATE:
01/06/2023
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Diana Paz, AdministratorTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Facility is not meeting resident's food service needs.
INVESTIGATION FINDINGS:
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LIcensing Program Analyst (LPA) Jill Nakagawa arrived unannounced on January 6, 2022 at approximately 10:15 AM to continue an investigation and deliver findings on an investigation conducted into the above allegation. LPA met with Administrator Diana Paz.

Record review revealed that Resident (R1)'s 602 had checked off “NO” to a special diet but the physician listed a Mechanical Soft/ Consistent Carbohydrate,Thin Liquids. The Dietary List used by the kitchen staff at the time of inspection (10/06/22) showed “Regular diet/ Allergic to none" indicating that the diet ordered by the physician for resident R1 was not being provided; therefore based on LPA's observations, interviews, and record reviews which were conducted the preponderance of standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2023
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/04/2022 and conducted by Evaluator Jill Nakagawa
COMPLAINT CONTROL NUMBER: 21-AS-20221004190046

FACILITY NAME:GRAND RIVER CARE CENTER-WESTFACILITY NUMBER:
577000418
ADMINISTRATOR:PAZ, DIANAFACILITY TYPE:
740
ADDRESS:509 MICHIGAN BOULEVARDTELEPHONE:
(916) 373-1591
CITY:WEST SACRAMENTOSTATE: CAZIP CODE:
95691
CAPACITY:30CENSUS: 22DATE:
01/06/2023
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Diana Paz, AdministratorTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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9
Resident fell while in care due to unlocked wheelchair.

INVESTIGATION FINDINGS:
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LIcensing Program Analyst (LPA) Jill Nakagawa arrived unannounced on January 6, 2022 at approximately 10:15 AM to continue an investigation and deliver findings on an investigation conducted into the above allegation. LPA met with Administrator Diana Paz.

Interview with resident revealed that Resident (R1) said that fall was due to resident unlocking (messing around) with wheelchair independently and moving around the facility. R1 was not being transferred at the time of fall; R1 was assessed by EMS and sent to hospital (10/30/21). Based on LPA's observations, interviews, and record reviews which were conducted a finding that resident fell while in care due to unlocked wheelchair was UNSUBSTANTIATED meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the allegation occurred.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2023
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 21-AS-20221004190046
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: GRAND RIVER CARE CENTER-WEST
FACILITY NUMBER: 577000418
VISIT DATE: 01/06/2023
NARRATIVE
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(Continued from 9099)

Deficiencies 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. Appeal rights were provided.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 21-AS-20221004190046
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: GRAND RIVER CARE CENTER-WEST
FACILITY NUMBER: 577000418
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/06/2023
Section Cited
CCR
87464 (f)(3)
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87464 Basic Services (f) Basic services shall at a minimum include:(3) Three nutritionally well-balanced meals and snacks made available daily, including low salt or other modified diets prescribed by a doctor as a medical necessity.
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Licensee agrees to conduct a training and audit with Dietary Staff and to ensure that special diets are being observed. Proof of audit and training to be submitted to LPA by 01/11/2023, after facility's in-service on same day.
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This requirement was not met as evidenced by: Based on record review, observation and interview, the facility did not provide the modified diet as prescribed by doctor. This poses a potential health and safety risk to 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: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4