577000418-5-7-2021-21-AS-BMOS-C35QNM-20210518121922

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 577000418
Report Date: 05/07/2021
Date Signed: 05/07/2021 10:55:58 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
03/05/2021 and conducted by Evaluator Marisol Cuadra

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20210305134117

FACILITY NAME:	GRAND RIVER CARE CENTER-WEST		FACILITY NUMBER:	577000418
ADMINISTRATOR:	DANA SBARBARO		FACILITY TYPE:	740
ADDRESS:	509 MICHIGAN BOULEVARD		TELEPHONE:	(916) 373-1591
CITY:	WEST SACRAMENTO	STATE: CA	ZIP CODE:	95691
CAPACITY:	30	CENSUS: 12	DATE:	05/07/2021
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Diana Paz (Administrator)		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Resident's needs are not being met.

INVESTIGATION FINDINGS:

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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 May 7, 2021 and on this date for the purpose of closing the complaint.
It was alleged by Reporting party that resident (R1) blood pressure has been running in the 200’s while residing at the facility and staff indicated to reporting party that blood pressure was taken once a month, but it was unclear when it was last checked. LPA obtained R1’s Physician Report which indicates a diagnosis of hypoglycemia, Individual Plan of Care dated 12/14/20 signed by R1, meal monitor, bowel movement records, blood sugar log and assistance with insulin signing sheet being monitored four times a day for the month of February 2021. Facility provided R1’s discharge documents dated 3/5/21 at 2:52pm indicated new order for Hypertensive urgency and changes to R1’s medications. Based on LPA investigation and records review there is no records that indicates R1 has an order for blood pressure to be taken prior to hospital visit. A finding that the complaint allegation Resident's needs are not being met 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.
No deficiencies cited during today's inspection

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2021

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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