Granite Bay Countryhouse Llc

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Facility staff are not properly administering medication to residents as prescribed

Licensing Program Analyst (LPA) Graham Gunby arrived unannounced on 06/17/2025 to complete and deliver findings to a complaint received on 01/13/2024. LPAs met with Office Manager, Lorraine Stafford and explained the purpose of the visit. Throughout the course of the investigation, the department conducted interviews and record reviews. Please continue to LIC9099C.. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jun 17, 2025 · control 59-AS-20250113151326

Allegation investigated: Staff did not properly assist resident with wound care. Staff did not seek medical attention to resident as needed. Staff did not provide a comfortable temperature to resident. Staff did not communicate with resident's authorized representative in a timely manner.

Licensing Program Analyst (LPA) Melissa Parks arrived unannounced on Tuesday October 1, 2024, to complete and deliver findings to a complaint received on 12/21/2023. LPA met with Goshong and explained the purpose of the visit. Throughout the course of the investigation, LPA interviewed the Administrator, staff, and hospice staff. LPA reviewed R1’s physicians report, death report, care plan, assessment, nursing notes, and outside agency notes. The result of the investigation is as follows: Allegations: Staff did not properly assist resident with wound care. Staff did not seek medical attention to resident as needed. LPA reviewed R1’s hospice notes. These were well documented nurse visits each time a hospice nurse visited R1 at the facility. Hospice notes always included any indication of pain and wound presence. LPA learned the following: R1 received weekly hospice visits which began around 10/12/2023 and ended when R1 passed in December. LPA reviewed nurse documentation on 11/13, 11/16the state’s words, verbatim · CDSS document, Oct 1, 2024 · control 59-AS-20231221093928

Allegation investigated: Facility is malodorous Staff did not meet residents' needs

LPA Parks and LPA Mikkelson arrived on Thursday September 12, 2024, to conclude a complaint investigation regarding the above allegations. LPA met with Administrator James Hall and explained the purpose of the visit. Throughout the course of the investigation, LPA interviewed the Administrator, Director of Nursing, and staff. LPA and Administrator toured resident apartments and common areas. The result of the investigation is as follows: Allegation: Facility is malodorous On the initial complaint facility visit, on July 26, 2024, LPA Parks and Administrator Hall toured the facility together. LPA inspected 5 apartments whose occupants incontinence needs were provided by staff. LPA did not observe any odor in the resident apartments. Furthermore, LPA Parks and Administrator Hall toured the common areas of the facility, and no odor was detected. Unfoundedthe state’s words, verbatim · CDSS document, Sep 12, 2024 · control 59-AS-20240723114956

Allegation investigated: Staff do not ensure the facility is free from pests. Staff do not ensure the facility is clean. Staff do not ensure laundry equipment is in good repair.

LPA Parks and LPA Mikkelson arrived on Thursday September 12, 2024, to conclude a complaint investigation regarding the above allegations. LPAs met with Administrator James Hall and explained the purpose of the visit. Throughout the course of the investigation, LPA interviewed the Administrator, Director of Nursing, and staff. LPA toured the facility with Administrator Hall. LPA reviewed pest control documentation. The result of the investigation is as follows: Allegation: Staff do not ensure the facility is free from pests. LPA interviewed staff who stated that they observed ants in R1’s room. Staff interviews also acknowledged that management has followed up with pest control and taken action in order to mitigate the issue. The facility supplied pest control invoices which show that the facility has routine pest control visits. Unsubstantiatedthe state’s words, verbatim · CDSS document, Sep 12, 2024 · control 59-AS-20240715152518

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff did not assist resident with protective boot Staff did not ensure that facility is free of pests

LPA Parks arrived on Friday May 3, 2024, to conclude a complaint investigation regarding the above allegations. LPA met with HR Assistant Goshong Vang and explained the purpose of the visit. Throughout the course of the investigation, LPA interviewed the Administrator, Director of Nursing, and staff. LPA reviewed observation notes for R1-R4. LPA reviewed pest control documentation. Additionally, LPA observed the apartments of R5 and R6 and the kitchen. The result of the investigation is as follows: Allegation: Staff did not assist resident with protective boot LPA reviewed R4’s hospice orders which stated that resident is to wear protective boots. LPA interviewed staff who stated that they always put the boots on R4. One interview acknowledged that agency staff have previously forgotten to put on the boots, but when observed by facility staff, this is corrected immediately. Unsubstantiatedthe state’s words, verbatim · CDSS document, May 3, 2024 · control 59-AS-20240412103029

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff neglect resulted in a resident to be hospitalized.

On 2/15/2024, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced to deliver final finding Community Care Licensing (CCL) received on 10/16/2023. LPA met with Executive Director, Leticia Higares, and explained the purpose of the visit. During the course of the investigation, the Department conducted interviews with facility staff, residents in care, relevant parties, and obtained pertinent documents relevant to the complaint investigation such as resident (R1) physician’s report, plan of care, assessments, and medical records. Continue on page LIC 9099-C. Substantiatedthe state’s words, verbatim · CDSS document, Feb 15, 2024 · control 59-AS-20231016155615

Allegation investigated: Facility disclosed resident confidential information to the wrong people. Staff did not provide resident's authorized representative with records in a timely manner Staff did not properly dispose of trash Staff are not following medication orders. Staff are not meeting residents' needs Staff did not notify resident’s authorized representatives of incidents

LPA Parks arrived on Thursday December 14, 2023, to conclude a complaint investigation regarding the above allegations. LPA met with Interim Executive Director Jackie Hernandez and explained the purpose of the visit. Throughout the course of the investigation, LPA interviewed the previous Administrator, previous Director of Nursing, Med techs, caregivers, dietary staff, and R1’s hospice nurse. LPA reviewed R1’s facility file including medication lists, MARs, and controlled substance count sheets. The result of the investigation is as follows: Allegations: Facility disclosed resident confidential information to the wrong people and Staff did not provide resident's authorized representative with records in a timely manner LPA reviewed emails between R1’s POA and the facility. The POA began requesting R1’s facility records on August 20, 2023. The POA sent a follow-up email on September 1, 2023, again requesting R1’s records. The facility emailed the POA some of R1’s file to the POA on Septhe state’s words, verbatim · CDSS document, Dec 14, 2023 · control 59-AS-20231003164146

Allegation investigated: Staffing shortage Lack of supervision

LPA Parks arrived on Thursday December 14, 2023, to conclude a complaint investigation regarding the above allegations. LPA met with Interim Executive Director Jackie Hernandez and explained the purpose of the visit. Throughout the course of the investigation, LPA interviewed the previous Administrator, previous Wellness Director, Med techs, caregivers, and dietary staff. Additionally, LPA interviewed R1’s hospice nurse and Administrator of current facility. LPA reviewed R1’s facility file in addition staffing schedules and employee timecards. The result of the investigation is as follows: LPA reviewed documentation which showed R1 had a weight loss of 21.6 pounds from May 4, 2023 through August 1, 2023. According to staff interviews, R1 required assistance with eating. This assistance varied from helping R1 get started with their meal to assisting with the entire meal. Staff acknowledged that R1 had a good appetite and usually ate most of their food. LPA interviewed a family friend ofthe state’s words, verbatim · CDSS document, Dec 14, 2023 · control 59-AS-20230802143046

Allegation investigated: Staff not supervising residents Resident sustained multiple fractures due to staff neglect

LPA Parks arrived on December 6, 2023, to deliver findings to two allegations from a complaint received on October 3, 2023. LPA met with Interim Executive DIrector Jackie Hernandez and explained the purpose of the visit. Throughout the course of the investigation, current and previous staff were interviewed. LPA reviewed R1’s facility file including medication lists, incident reports, observation logs, MARs, care plans, and controlled substance count sheets. The result of the investigation is as follows: R1 sustained two falls on 8/27/2022 and 5/29/2023 that resulted in serious injuries. The 8/27/2022 fall was a witnessed fall and R1 sustained a fractured left fibula and was placed in a split. Per the observation notes, R1 was attempting to walk on their own and collapsed on the floor. The 5/29/2023 fall was an unwitnessed fall and R1 sustained a “nondisplaced hairline fracture of radial head.” Per R1’s observation notes and Incident Report, R1 was found outside in the pond by their spthe state’s words, verbatim · CDSS document, Dec 6, 2023 · control 59-AS-20231003164146

Allegation investigated: Resident(s) sustained falls resulting in injury due to lack of care and supervision. Facility staff did not follow physician orders. Staff handle resident(s) in a rough manner.

LPA Parks arrived on Tuesday September 19, 2023, to conclude a complaint investigation regarding the above allegations. LPA met with Administrator Jessica and explained the purpose of the visit. Throughout the course of the investigation, LPA interviewed the Administrator, Wellness Director, Med techs, and caregivers. LPA reviewed R1’s file including physicians report, medication list, observation notes, and various other documents. The result of the investigation is as follows: LPA was at the facility the day R1 had two falls. LPA observed R1’s falls occur in the common area of the facility. Both times, there were staff in the common area who responded immediately to the fall. Additionally, staff interviews acknowledged that resident was being supervised at the time the falls occurred. LPA reviewed text messages between the Wellness Director and hospice nurse regarding a bed rail. Per new regulations, R1’s POA needed to sign authorization for a half rail for R1’s hospital bed. Bed raithe state’s words, verbatim · CDSS document, Sep 19, 2023 · control 59-AS-20230901112315

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.