577000418-2-23-2024-21-AS-KMOA-CUTS3G-20230818133106

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 577000418
Report Date: 08/14/2023
Date Signed: 02/23/2024 10:30:29 AM

Unsubstantiated

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
07/03/2023 and conducted by Evaluator Farhaan Sarangi

COMPLAINT CONTROL NUMBER: 21-AS-20230703111832

FACILITY NAME:	GRAND RIVER CARE CENTER-WEST		FACILITY NUMBER:	577000418
ADMINISTRATOR:	PAZ, DIANA		FACILITY TYPE:	740
ADDRESS:	509 MICHIGAN BOULEVARD		TELEPHONE:	(916) 373-1591
CITY:	WEST SACRAMENTO	STATE: CA	ZIP CODE:	95691
CAPACITY:	30	CENSUS: 28	DATE:	08/14/2023
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Administrator, Diana Paz		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff are overdosing residents
Staff are not repositioning residents
Staff left residents in soiled diapers for an extended period of time
Staff speaks rudely towards residents
Staff are not keeping resident personal information confidential

INVESTIGATION FINDINGS:

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**** AMENDED REPORT DUE TO APPEAL BEING UPHELD****
Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Grand River Care Center-West for the purpose of continuing on an investigation and delivering findings. LPA was greeted at the door by, Administrator, Diana Paz, and was granted access into the facility.

During the course of the investigation, LPA interviewed staff and residents in care. In addition, LPA toured the facility on August 14, 2023 and reviewed a sample population of resident records, facility records, medication orders and Medication Assessment Records (MARs).

Complaint alleges that staff are overdosing residents. Based on interviews that were conducted, LPA could not prove or disprove the allegation due to inconsistent statements made throughout the course of the investigation. Furthermore, LPA learned of no concerns throughout the interviews with residents in care. LPA conducted a review of the Medication Orders and the Medication Assessment Record (MAR) and found no evidence to suggest overmedicating of residents. (Report continued on LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Jill Nakagawa	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2023

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 5

Control Number 21-AS-20230703111832

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: 08/14/2023

NARRATIVE

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Complaint alleges that Staff are not repositioning residents. Based on interviews that were conducted, LPA could not prove or disprove the allegation. In addition, LPA received inconsistent statements during interviewing. LPA conducted a file review of a sample population of residents and found no evidence to suggest that the staff are not repositioning the residents.

Complaint alleges that Staff left residents in soiled diapers for an extended period of time. Based on interviews that were conducted, LPA learned of no concerns regarding staff attentiveness to residents in care during incontinence episodes.

Complaint alleges that Staff speaks rudely towards residents. Based on interviews that were conducted with residents in care, LPA learned of no concerns regarding staff to resident interactions. Residents were observed to be content and happy in placement.

Complaint alleges that Staff are not keeping resident personal information confidential. Based on interviews that were conducted with staff, there were inconsistent information during interviewing. LPA could not corroborate the allegation.

A finding that the complaint allegations of Staff are overdosing residents, Staff are not repositioning residents, Staff left residents in soiled diapers for an extended period of time, Staff speaks rudely towards residents and Staff are not keeping resident personal information confidential are unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted and a copy of this was report was signed and given to the Administrator.

**** AMENDED REPORT DUE TO APPEAL BEING UPHELD**** See 9099-A

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Jill Nakagawa	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

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
07/03/2023 and conducted by Evaluator Farhaan Sarangi

COMPLAINT CONTROL NUMBER: 21-AS-20230703111832

FACILITY NAME:	GRAND RIVER CARE CENTER-WEST		FACILITY NUMBER:	577000418
ADMINISTRATOR:	PAZ, DIANA		FACILITY TYPE:	740
ADDRESS:	509 MICHIGAN BOULEVARD		TELEPHONE:	(916) 373-1591
CITY:	WEST SACRAMENTO	STATE: CA	ZIP CODE:	95691
CAPACITY:	30	CENSUS: 28	DATE:	08/14/2023
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Administrator, Diana Paz		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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9

Staff are mismanaging residents medication

INVESTIGATION FINDINGS:

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**** AMENDED REPORT DUE TO APPEAL BEING UPHELD****
Licensing Program Analyst (LPA) Nakagawa arrived unannounced at Grand River Care Center-West for the purpose of delivering amended complaint findings from original report delivered 8/14/2023. LPA was greeted by Diana Paz and was granted access into the facility.

During the course of the investigation, LPA interviewed staff and residents in care. In addition, LPAs toured the facility on August 14, 2023 and February 23, 2024. LPA reviewed a sample population of resident records, facility records, medication orders and Medication Assessment Records (MARs).
(Continued on 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Jill Nakagawa	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2023

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 5

Control Number 21-AS-20230703111832

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: 08/14/2023

NARRATIVE

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Continued from 9099A...

**** AMENDED REPORT DUE TO APPEAL BEING UPHELD****

Complaint alleges that Staff are mismanaging residents’ medication. During the course of the investigation, LPA reviewed the LIC 602 for Resident #5 and learned that the resident is not able to manage medications on their own. LPA conducted a review of the Medication Orders and the Medication Assessment Record (MAR) and observed that Resident #5's MAR was not initialed. In addition, LPA and Med tech inspected the Medication Cart and observed one over the counter (OTC) medication that was missing from the cart. Upon further investigation, it was revealed that R5’s responsible party had not provided the OTC to the facility and the facility had properly reported to R5’s physician.

LPA educated the Administrator and the Med Tech on the importance of ensuring that all medications are dispensed as outlined in the Medication Orders.

A finding that the complaint allegation of Staff are mismanaging residents medication 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. Exit interview was conducted and a copy of this was report was signed and given to the Administrator.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Jill Nakagawa	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Citations on this Visit Report are Under Appeal!

Control Number 21-AS-20230703111832

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: 08/14/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Under Appeal Type A 08/15/2023 Section Cited CCR 87465(c)(2)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care: (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.	1 2 3 4 5 6 7	Plan of Correction shall include submitting a LIC 9098-Self Certification Form and ensuring that ALL residents medications are kept in the cart and given based off of physician instructions. In addition, Licensee/Administrator shall provide a written summary on how future compliance will be met and a plan on when training will be conducted.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on observation of the LIC 602 and the inspection of the Medication Cart with the Med Tech, resident is not able to manage medications on their own. LPA conducted a review of the Medication Orders and the Medication Assessment Record (MAR) and observed that Resident #5's MAR was not initialed. In addition, LPA and Med tech inspected the Medication Cart and observed one medication that was missing from the cart which presents a immeidate health, safety and Personal Rights risk to the residents in care.	8 9 10 11 12 13 14	Facility shall conduct staff training with ALL staff members on the importance of ensuring that medications are given timely, storage of medications, dispensing medication and documentation of when medication is dispensed. A statement for future compliance will be sent by Close of Business Day (COB) August 15, 2023. POC Due Date as it relates to the training: August 28, 2023.
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	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: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2023

LIC9099 (FAS) - (06/04)

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