<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 577000418
Report Date: 02/22/2021
Date Signed: 02/22/2021 10:35:23 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
01/29/2021 and conducted by Evaluator Marisol Cuadra
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20210129160345
FACILITY NAME:GRAND RIVER CARE CENTER-WESTFACILITY NUMBER:
577000418
ADMINISTRATOR:DANA SBARBAROFACILITY TYPE:
740
ADDRESS:509 MICHIGAN BOULEVARDTELEPHONE:
(916) 373-1591
CITY:WEST SACRAMENTOSTATE: CAZIP CODE:
95691
CAPACITY:30CENSUS: 13DATE:
02/22/2021
UNANNOUNCEDTIME BEGAN:
10:11 AM
MET WITH:Diana Paz (Administrator)TIME COMPLETED:
11:15 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility failed to obtain signed admission agreement of responsible party upon admission of dementia resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Marisol Cuadra conducted a complaint investigation regarding the above allegations. Tele-visit with Administrator, Diana Paz was conducted due to COVID-19 precautions on February 22, 2021 and on this date for the purpose of closing the complaint.

During this investigation LPA reviewed records provided by facility. Based on records review of resident’s (R1), was transferred from Fruitridge Villa on 12/16/2020, responsible party was notified of the move of R1 due to closure of facility. On Admission Agreement obtained dated 12/16/2020 was signed by R1 who has a diagnosis of Dementia on their Physician’s Report (LIC602) dated June 20, 2020. Also, on ID/Emergency Contact Information (LIC601) indicates that R1 is not “mentally capable”.

The preponderance of evidence standard has been met, therefore the above allegation of Facility failed to obtain signed admission agreement of responsible party upon admission of dementia resident is found to be SUBSTANTIATED. Health and Safety Code is being cited on the attached LIC 9099D. Appeal Rights Given.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2021
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 3
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
01/29/2021 and conducted by Evaluator Marisol Cuadra
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20210129160345

FACILITY NAME:GRAND RIVER CARE CENTER-WESTFACILITY NUMBER:
577000418
ADMINISTRATOR:DANA SBARBAROFACILITY TYPE:
740
ADDRESS:509 MICHIGAN BOULEVARDTELEPHONE:
(916) 373-1591
CITY:WEST SACRAMENTOSTATE: CAZIP CODE:
95691
CAPACITY:30CENSUS: 13DATE:
02/22/2021
UNANNOUNCEDTIME BEGAN:
10:11 AM
MET WITH:Diana Paz (Administrator)TIME COMPLETED:
11:15 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Personal Rights
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Marisol Cuadra conducted a complaint investigation regarding the above allegation. Tele-visit with Administrator, Diana Paz was conducted due to COVID-19 precautions on February 22, 2021 and on this date for the purpose of closing the complaint.

During this investigation LPA reviewed records and conducted confidential interviews. Based upon review of resident records and confidential interviews conducted on 02/08/2021 with 8 out of 13 resident’s responsible parties. Although complainant alleges that facility did not notify resident’s responsible parties of the facility Covid-19 positives on February 1, 2021; LPA interviews conducted revealed no additional information to support this allegation.

A finding that the complaint allegation Personal Rights is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20210129160345
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: GRAND RIVER CARE CENTER-WEST
FACILITY NUMBER: 577000418
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
03/05/2021
Section Cited
CCR
87507(c)
1
2
3
4
5
6
7
87507 Admission Agreements (c) Admission agreements shall be signed & dated, acknowledging the contents of the document, by the resident or the resident’s representative...no later than seven days following admission... This requirement has not been met as evidence by:
1
2
3
4
5
6
7
Licensee to ensure that facility Admission Agreement are signed in compliance with regulations. Licensee to provide a copy of R1 admission agreement signed by R1’s responsible party by POC due date of 3/5/2021.
8
9
10
11
12
13
14
Based on LPA’s records review and confidential interviews conducted, Licensee did not ensure that R1’s Admission Agreement was signed by R1’s responsible party which poses a potential risk to the health and safety of 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: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3