Grand River Villa

Allegation investigated: Staff did not transfer resident per Care Plan leading to injury.

Licensing Program Analyst (LPA) Nakagawa arrived unannounced at Grand River Villa on 8/7/2026 to conclude a complaint investigation and deliver findings. LPA met with Roberto Negrete, Med. Tech. Robert Godfrey, Administrator was notified by phone to discuss findings. The complaint alleges that Staff did not transfer resident per Care Plan leading to injury. Resident (R1) requires staff assistance with transferring between bed and wheelchair. Complainant alleges staff improperly transferred R1 causing injury. The Department conducted an investigation which included reviewing records and conducting interviews. Interviews of 5 of 5 staff did not identify how R1 sustained an injury. (Continued on 9099-C) Unsubstantiated (Continued from 9099-C) The Department’s review of medical records were inconclusive to determine who caused the injury to R1. LPA reviewed staff training records and found that 10 of 10 staff have proper training per Title 22 Regulations. LPA was able to interview R1 but R1 was unable to identify how injury occurred. Based on the Department's investigation unable to identify a witness to who caused injury to R1, and R1 unable to identify a staff who caused how the injury occurred, the allegation that Staff did not transfer resident (R1) per Care Plan leading to injury is unsubstantiated. 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 unsubstantiated.the state’s words, verbatim · CDSS document, Aug 7, 2026 · control 21-AS-20260219141943

Type of visit: Required - 1 Year

On 07/29/2026, Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced and was greeted by Regional Nurse, Allison Lopez. Administrator Robert Godfrey arrived shortly. The purpose of the visit is an Annual Inspection. There are currently 21 residents residing at the facility. There were 2 caregivers and one med tech at the time of inspection, as well as the Regional Nurse, the Administrator, Dietary Lead and Regional Maintenance Director. LPA inspected the facility's kitchen and found it clean and well organized, with an ample supply of perishable and non-perishable foods, as required per Title 22. There were also emergency supplies stored. LPA discussed an updated menu. Kitchen knives are locked in storage closet in kitchen when not in use. Residents' rooms were clean and furnished as per regulation. Bathrooms had soap and paper towels. Water temperature measured between 105 and 114 degrees F, which is within regulation. Common areas including the dining room, activities room and the Great Room were all clean and well organized. Medications were locked and stored in general office and on the medication cart. Fire extinguishers throughout the building were fully charged. The last fire drill took place on 07/28/2026 and the last fire inspection was on 06/09/2025. Carestaff do several activities over the course of the day including chair exercise, BINGO, bible study, arts and crafts. The outdoor areas were free from debris and all windows had screens. The outdoor courtyard provides seating for residents and visitors, but relies on shade trees to provide shade to the area. Three (3) resident files and five (5) staff files were reviewed and found to be complete. Facility is switching over to electronic file system. LPA requested that Administrator review training records and transcripts and organize. LPA requested an updated LIC500, proof of Liability Insurance, updated Emergency Disaster Plan, updated Infection Control Plan. No deficiencies found at the time of inspection. No citations. Exit interview conducted with Administrator Robert Godfrey.the state’s words, verbatim · CDSS document, Jul 29, 2026

Allegation investigated: Staff sexually abused resident. Staff does not accord resident privacy. Staff isolates resident.

On 04/24/2026, Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to complete the investigation regarding the above allegations and met with Regional Administrator Robert Godfrey. The Department conducted an investigation regarding the allegation Staff sexually abused resident and determined that Resident (R1) failed to disclose being raped or sexually assaulted when interviewed. The reporting party was unable to provide any information or evidence to support R1’s allegation. Interviews of two residents failed to provide information to support the allegation and/or any allegations or complaints similar in nature. Interviews with four staff, including the Administrator, failed to reveal any information or evidence to support the allegation. Continued on 9099-C Unsubstantiated Continued from 9099... According to West Sacramento Police Department, an attempt to interview R1 was initiated by the responding officer but R1’s response to questions was incoherent and rambling. Based on statements made by residents, staff, and R1, and failed investigative efforts by police to substantiate the allegation, no information or evidence was uncovered to support the allegation. The complaint alleges that Staff does not accord resident (R1) privacy. The complainant stated that R1 at times complains that they have too many visitors and is overwhelmed. LPA observed that R1 had visitors including family, church members, and health care providers. There was no record of R1 refusing the visits of staff or visitors. In addition, LPA observed on 01/26/2026 and 02/03/2026 that the door was closed during visits by staff and health care workers. Based on LPA’s observations and interviews the allegation that Staff does not accord R1 privacy is unsubstantiated. Although the allegation may have occurred there is not a preponderance of evidence to verify the allegation therefore the allegation is UNSUBSTANTIATED. The complaint alleges that Staff isolates resident. The complainant stated that R1 feels isolated although complainant reported that R1 has 2 volunteers, a chaplain, a social worker, Home Health Aides and an RN who visit R1 plus visits from family and friends from church. Staff also reported that R1 uses a phone in their room to make and receive calls. In addition, staff reported that R1 is taken to the dining room for meals when they request. Based on LPA’s observations on 01/26/26 and 02/03/2026, interviews with staff, home health aides and review of Visitor Sign-In Sheets the allegation that Staff isolates resident is UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Apr 24, 2026 · control 21-AS-20260123152701

Allegation investigated: Facility failed to safeguard residents belongings

On 04/24/2026, at approximately 3:08 PM, Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to complete a complaint investigation and to deliver findings. LPA met with Regional Administrator Robert Godfrey. . The complaint alleges that the Facility failed to safeguard resident’s belongings. The complainant stated that they went to retrieve the chair of Resident (R1) upon their passing but was unable to recover the chair as it was missing. LPA questioned 4 facility staff regarding the chair. 4 of 4 staff stated the chair of resident R1 was at the facility, currently located in the Activities Room. Continued on 9099-C.... Unsubstantiated Continued from 9099.... Family members of R1 were asked if they had a picture of the chair but were unable to provide one, but stated “Although the chair (currently in the Activities Room) was similar to that of R1 they did not believe it to be the same. One of two family members stated the one at the facility was more orange than the brown one of R1. The second family member stated that the chair had been labeled and the chair shown had no label and was not in the same condition as the chair belonging to R1. Staff (S1) was able to provide a picture from a year ago in February of 2025. It shows staff member (S2) sitting in a chair that looks very much like the chair identified by staff as R1’s chair, in R1’s room. Although the chair looks like the same chair that is now at the facility, LPA cannot conclusively identify the chair is one in the same without a picture provided from friend or family. LPA examined the chair and found no labels discerning the chair as that of R1: staff were certain it was, but friends and family were not, and there is no record of the chair in R1’s Inventory List. Based on LPA’s conversations with individuals, both staff and family, and lack of photographic or physical evidence submitted by complainant, the allegation that the facility failed to safeguard resident’s belongings is unsubstantiated. Although the allegation may have occurred there is not a preponderance of evidence therefore the allegation is UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Apr 24, 2026 · control 21-AS-20260227111415

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Nakagawa arrived to conduct a case management visit regarding an incident report submitted to Community Care Licensing (CCL) for R1 which occurred on 10/03/2025. LPA met with Luceli Soto-Luis, the newly appointed Administrator. R1 eloped while under facility responsibility. Resident R1 has a physician's report dated 02/22/2024 diagnostic of dementia which states that resident is NOT able to leave facility unassisted at any time. Per facility staff resident R1 was found by family member of staff on sidewalk in community and returned to facility; staff were unaware that R1 had eloped. Due to this incident, immediate elopement training for staff will be held, the front gate will be repaired, new walky-talky protocols will be established. Additionally, a wander-guard system is being considered for installation. The following deficiency was observed (see LIC 809D) and 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. Exit interview conducted and appeal of rights provided. Appeal of Rights Given.the state’s words, verbatim · CDSS document, Oct 15, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(c) · Plan of correction due date: Oct 15, 2025

87464 Basic Services(f) Basic services shall at a minimum...(c) "Care and supervision" means the facility assumes...safety, personal care.:. This requirement is not met as evidenced by: Based on incident report and staff interview Resident R1 eloped from facility without staff knowledge on 10/03/2025. This poses an immediate risk to the safety and health of residents in care.the state’s words, verbatim · CDSS document, Oct 15, 2025

Plan of correction: Administrator agrees to conduct staff training regarding elopment by 10/16/2025 and will have plan for gate repair and wander guard to LPA by 10/17/2025.

Type of visit: Required - 1 Year

On 07/14/2025, Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced and was greeted by Resident Care Coordinator Maria Ortiz, Administrator Magda Luis arrived shortly. The purpose of the visit is an Annual Inspection. There are currently 25 residents residing at the facility. There were 2 caregivers and one med tech at the time of inspection, as well as the Resident Care Coordinator, the Administrator, cook and maintenance director. LPA inspected the facility's kitchen and found it clean and well organized, with an ample supply of perishable and non-perishable foods, as required per Title 22, however Administrator will ensure that supplies listed on the menu are available whenever possible. Kitchen knives are locked in storage closet in kitchen when not in use. Residents' rooms were clean and furnished as per regulation. Bathrooms had soap and paper towels. Water temperature measured between 115.3 and 116.9 degrees F, which is within regulation. Common areas including the dining room, the activities room and the Great Room were all clean and well organized. The outdoor courtyard was currently not in use due to a crew cleaning out and disposing of contents in storage unit. Removal of refuse is due to take place on this date, 07/14/2025. A recent gardening project completed by residents was visible through the dining room windows. Medications were locked and stored in general office and on the medication cart. Proof of Liability Insurance was provided. Fire extinguishers throughout the building were last charged and tested on 11/23/2024. The last fire drill took place on 04/15/2025 and the last fire inspection was on 06/09/2025. An Activities Calendar was posted with several activities occurring over the course of the day including chair exercise, BINGO, bible study. LPA reviewed 5 resident files and 5 staff files and found them to be complete. LPA discussed the importance of in-person First Aid/CPR training. Administrator stated initial First Aid/CPR training in-person with refresher courses being completed on-line. No deficiencies cited. Exit interview conducted with Administrator, Magda Luis.the state’s words, verbatim · CDSS document, Jul 14, 2025

Type of visit: Case Management - Other

On 11/14/2024, Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced and was greeted by Resident Care Coordinator Maria Ortiz. The purpose of the visit is to follow up on the plan of correction for a previous deficiency and a health & safety check. There are currently 29 residents under the facility's care. LPA inspected the facility's kitchen and found an ample supply of perishable and non-perishable foods, as required per Title 22. Licensee provided visit by dietician to help in training dietary staff. The plan of correction for deficiency cited on 11/05/2024 has been met. No deficiency cited. Exit interview conducted with Maria Ortiz, Resident Care Coordinator for Robert Godfrey, Administrator.the state’s words, verbatim · CDSS document, Nov 14, 2024

Type of visit: Post Licensing

On November 5, 2024, Licensing Program Analyst (LPA)Jill Nakagawa arrived unannounced to conduct a Post-Licensing inspection for Grand River Villa. LPA met with Maria Ortiz, Resident Care Coordinator. There are currently 29 residents at this Resident Care Facility for the Elderly, with an approved fire clearance for 43 non-ambulatory and 7 bedbound residents. It is a single story building with 23 rooms, an activity room, dining room, living room and enclosed backyard. There were no accessible bodies of water or firearms. The fire extinguishers were last inspected on 10/23/2024 and fully charged. LPA inspected the grounds of the facility and found them to be well-maintained. A recent fire of the storage shed in the back yard was completely cleaned up and all debris removed. No damage to facility occurred. LPA observed locked box for knives and other sharps in the storage closet in the kitchen and a container in the medication room. Kitchen was clean and well-equipped with an adequate supply of dishes and utensils. There was not an adequate supply of perishable and non-perishable foods as required per regulation(See 809-D). Bathrooms had slip mats and grab-bars for resident safety. Hand soap is supplied for handwashing. New paper towel dispensers are being installed in each resident restroom to replace other means. Water temperature was between 105 - 115 degrees F, which is within regulation. A tour of residents' bedrooms was conducted and bedrooms inspected have lighting and appropriate furnishings and linens. LPA observed the Let Us Know Complaint poster and See Something Say Something poster. Updated Emergency Disaster Plan and Administrator Certificate to be posted. Continued on 809-C Continued from 809.... Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview was conducted with Administrative Assistant and a copy of this report was given.the state’s words, verbatim · CDSS document, Nov 5, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(26) · Plan of correction due date: Nov 5, 2024

87555 General Food Service Requirements (b) The following food service requirements shall apply:(26)Supplies of nonperishable foods for a minimum of one week.. perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by: Based on LPA's observation Licensee failed to ensure that there were adequate perishable and non-perishable foods available for the required time frame for a minimum of 29 residents.the state’s words, verbatim · CDSS document, Nov 5, 2024

Plan of correction: Licensee to submit proof of purchase of food by 11/07/24 to LPA to ensure adequate food supply ison site of facility.

Type of visit: Prelicensing

Licensing Program Analyst (LPA)Jill Nakagawa arrived unannounced to conduct a Pre-Licensing inspection for Grand River Villa, previously Grand River Care Center-West. There are currently 27 residents at this Resident Care Facility for the Elderly, with an approved fire clearance for 36 non-ambulatory and 7 bedbound residents. It is a single story building with 23 rooms, an activity room, dining room, living room and enclosed backyard. There were no accessible bodies of water or firearms. The fire extinguishers were last inspected on 10/18/2023 and fully charged. LPA observed locked box for knives and other sharps in the storage closet in the kitchen and a container in the medication room. Kitchen was clean and well-equipped with an adequate supply of dishes and utensils. Two refrigerators and one freezer were clean, with an adequate supply of perishable and non-perishable foods. Bathrooms had slip mats and grab-bars for resident safety. Hand washing supplies and paper products were available in sinks used by residents. Water temperature was between 112-116 degrees F, which is within regulation. A tour of residents' bedrooms was conducted and bedrooms inspected have lighting & appropriate furnishings and linens. LPA observed the required postings including: emergency disaster plan, the Let Us Know Complaint poster and See Something Say Something poster. Continued on 809-C Continued from 809.... A sample of 3 resident and 3 employee files were reviewed and found to be complete. LPA waived the COMP 3 with ; some of Administrator as they have been with the facility for several years and has a good understanding of Title 22 regulations as well as reporting requirements. . The pre-licensing evaluation has been completed. Applicant has satisfied all requirements in accordance with Title 22, California Code of Regulations. License will be granted upon completion of a final review and approval from the Licensing Program Manager. This report will be forwarded to the Licensing Program Manager and Centralized Application Unit for continued processing. This report was signed by Administrator's representative and a copy was provided. No deficiencies were cited during today's visit.the state’s words, verbatim · CDSS document, Jul 29, 2024

Type of visit: Office

Facility Type: RCFE Application Type: CHOW Capacity: 43 Census (if any clients in care): 27 COMP II Participants: Diana Paz, admin; Mark Cimino, member Interview Method: Telephone interview On July 15, 2024, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Medication Storage; locations of meds, fire drills 3. Transportation; filling current vacancies 4. Pre Licensing inspection readinessthe state’s words, verbatim · CDSS document, Jul 15, 2024