Wellquest Granite Bay Tenantco

Allegation investigated: -Staff administered wrong medication to resident resulting in medical care -Staff are not properly trained -Staff did not report incident to licensing

Licensing Program Analyst (LPA) Angela Hood arrived at the care home today and met with the Executive Director (ED), Charles Russell, to deliver complaint investigation findings regarding the above stated allegations. During the course of the investigation, LPA obtained documentation pertinent to the investigation and conducted an interview. LPA interviewed ED regarding an incident that occurred on April 22, 2026 or April 23, 2026 involving staff (S1) administering the wrong medication to a resident. ED indicated that there were no incidents regarding mismanagement of medications. ED indicated that there was an incident on April 23, 2026 with resident (R1). *********************************************Continued on LIC9099-C**************************************************** Unfounded An Unusual Incident/Injury Report LIC624 was submitted to CCLD on April 28, 2026 regarding the April 23, 2026 incident. R1 had called for assistance and staff (S1) responded to the call. R1 indicated that they were not feeling well and reported that they were nauseous, sweating, and shaky. Emergency medical was contacted and upon arrival assessed R1. R1 refused transport to the hospital. The facility contacted R1's primary care physician (PCP) and responsible party. As a result of the incident, the facility began frequent checks of R1 to monitor for any changes or concerns. On April 24, 2026, R1 called for assistance as they were still not feeling well. Emergency medical was contacted and R1 was transported to the hospital. The facility submitted an Unusual Incident/Injury Report to CCLD on April 28, 2026. According to R1's Medical Assessment LIC602A dated April 8, 2026, R1 was able to administer their own prescription and PRN medications, as well as store their own medications. Interview with ED indicated that, as of April 15, 2026, R1 was able to store and administer their own medications. ED indicated that the facility began medication management for R1 on April 25, 2026. R1's Health and Services Evaluation dated April 15, 2026 indicated that they were able to self administer their own medications. R1's Health and Services Evaluation dated April 24, 2026 indicated that the facility began providing assistance with R1's medications. An Unusual Incident/Injury Report LIC624 was submitted to CCLD on April 27, 2026 regarding an incident that occurred on April 22, 2026 involving resident (R2). R2 had called for assistance from the dining room. S1 responded and R1 reported that they were having shortness of breath. Emergency medical was contacted and assessed R2. R2 refused transport to the hospital. The facility contacted R2's PCP and responsible party. As a result of the incident, the facility began frequent checks of R2. R2 reported that they were feeling ok after the incident. No further incidents occurred. According to R2's Health and Services Evaluation dated February 15, 2026, they were independent with medication and were able to self administer their own medications. Neither incident from April 22, 2026 and April 23, 2026, regarding R1 or R2, involved administering the wrong medication to a resident resulting in medical care. Both incidents were reported to CCLD within seven (7) days of the occurrences. ***********************************************Continued on LIC9099-C********************************************** LPA reviewed S1’s training documentation, and S1 had completed all required training, as well as Med Tech training. On May 14, 2026, LPA conducted a separate inspection and reviewed six (6) additional staff members’ personnel files (S2, S3, S4, S5, S6, and S7). S2, S3, S4, S5, S6, and S7 had completed all training in accordance with regulatory requirements. Based on documentation obtained and interviews conducted, the above allegations are found to be UNFOUNDED. A finding that the allegations are unfounded means that the allegations are false, could not have happened, and/or are without a reasonable basis. No deficiencies are being cited. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 18, 2026 · control 59-AS-20260515100854

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Angela Hood arrived at the facility unannounced and met with the Executive Director, Charles Russell, to conduct a Required-1 Year Inspection. LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. LPA observed four (4) bedrooms in assisted living, four (4) bedrooms in memory care, and common area bathrooms. LPA observed apartments to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition and properly maintained. LPA checked the water temperature in two (2) downstairs apartments and two (2) upstairs apartments. The hot water temperatures were observed to be 109.3, 108.6, 109.7, and 109.4 degrees F. LPA checked the kitchen area for the ability to prepare and store food. Care home has required (2) two-day perishable and (7) seven-day non-perishable food supply on hand. LPA observed knives, cleaning products and other toxins to be locked away and inaccessible to residents. LPA observed the outdoor area and perimeter of the care home to be free of clutter and debris and there appeared to be no potential safety hazards to the residents in care. Smoke and carbon monoxide detectors are operational. Fire extinguishers and first aid kits are maintained and ready for emergency use. LPA checked medication storage and found medications to be locked away and inaccessible to the residents. LPA reviewed six (6) resident files and also reviewed six (6) staff files. As a result of this visit, no deficiencies were cited per California Code of Regulations, Title 22. Exit interview conducted and copy of report provided.the state’s words, verbatim · CDSS document, May 14, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a follow up case management inspection and met with Nekia Xavier, Health and Wellness Director, and Mike Talani, Administrator. LPA explained the purpose of the inspection was to deliver findings for an investigation the Department's Investigative Bureau (IB) conducted regarding the non-hospice death of (R1) in May 2025. During the course of the investigation, the Department interviewed multiple facility staff, residents and reviewed extensive documentation, including hospital medical records, facility physician's reports, care plans, the incident report (LIC624), and charting notes for (R1). The results of the investigation are as follows: Resident (R1) was found on the ground in their room on May 17, 2025, (0808 hours) during morning rounds, and appeared confused and complained of pain in their shoulders. Staff called 9-1-1 and resident was sent out for further medical treatment as having a possible stroke. (R1's) urinalysis revealed a possible infection and (R1) was admitted to the Intensive Care Unit (ICU) with a diagnosis of septic shock, secondary to Urinary Tract Infection (UTI). (R1) passed on May 17, 2025 (1937 hours), and their immediate cause of death is noted as septic shock , with an underlying cause of a Urinary Tract Infection (UTI). Multiple facility residents were interviewed and did not express any significant concerns about their health or safety living at the facility. During staff interviews, it was revealed that (R1)had a history of migraines; however, facility staff indicated they had no prior knowledge of (R1) having frequent UTI's and (R1) did not show any signs/symptoms for this prior to being hospitalized. Staff and facility documentation shows that (R1) was independent of services, had meals delivered to their room, and there were no significant changes in (R1's) condition leading up to the fall, including any signs of a UTI. The Health and Wellness Director stated (R1's) only symptom, before being sent to the hospital, was a headache/migraine, which was a chronic issue. *cont on 809C-1... 809C-1.. One staff stated (R1's) fall detect alerted the staff who responded right away and (R1) stated they were "okay" but was in an out of consciousness. One staff recalls (R1) falling a week before and had scratched her head; however, (R1) refused to go to the hospital. EMS was contacted also at that time. Facility charting notes document that (R1) refused to go out for further medical treatment, on 4/23/2025, after falling and when the Emergency Medical Technicians were called. The fax cover page also documents this. (R1's) Physician's Report (dated 4/24/2024) notes resident has a history of migraines, Mild Cognitive Impairment, is independent with all ADL's, and can self administer medications. Charting notes also document that on 5/13/2025 (2:47 pm), (R1) reported not feeling well due to having migraines. (R1's) responsible person was contacted and stated that migraines are normal for (R1), they are on medication and have a follow up appointment at the end of the month. At 9:40 pm, on 5/13/2025, (R1) was checked on again and "no issues were noted- staff to continue to monitor". There were no additional notes made until resident fell on the morning of 5/17/25. Those notes state that on 5/17/25 (10:04 am) (R1) had an unwitnessed fall in their apartment and was found on the floor. Resident was complaining of pain in both shoulders and their body was shaking while on the floor. Resident appeared confused and stated they lived at a prior care facility. 911 was called for evaluation and resident was taken to Emergency Room. Hospital notes indicate that 911 responders noticed a facial droop and confusion. The Physician's Report (dated 6/18/2024) says (R1) did not require assistance with mobility, transferring, bathing, grooming, dressing and toileting and was independent with medications. (R1's) responsible person was notified and asked that staff ensure medications were available to (R1) as they had an upcoming doctor's appointment. Hospital medical records note a primary cause of death as Urinary Tract Infection (UTI) and a secondary cause as Septic Shock. The county death certificate notes the immediate cause of death to be Septic Shock (onset of hours) and a UTI (onset of days). The administrator discussed and provided documentation showing that migraines and UTI's have many of the same signs/symptoms. Based on information obtained, the Department was not able to substantiate that (R1) passed due to the facility's staff neglect/failure to seek timely medical care. Also, it was clarified during today's inspection that staff (S1), who was interviewed during the investigation, is appropriately cleared/associated to the facility and had a name change. Exit interview. Copy of report provided.the state’s words, verbatim · CDSS document, Dec 11, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection and met with Marguerite Guerrero, Business Office Director and Mike Talani, Administrator, and explained purpose of inspection. The purpose of this case management inspection is to gather documents from a resident's file (R5) who unexpectedly passed in May 2025 and to discuss the following recent incident reports submitted on June 25, 2025. Resident (R1) had an unwitnessed fall on June 23, 25 (9:25 pm) while trying to grab a soda from the refrigerator. Resident sustained a bump on their head and was evaluated by Emergency Medical Technician's (EMT's). Resident refused to go to the emergency room when being evaluated, so the EMT's spoke with resident's family member after determining resident seemed to be fine. Resident was monitored and is doing fine and has not fallen again. Resident is not prone to falls. Resident (R2) had an unwitnessed fall on June 22, 2025 (3:48 am) and was found face down next to their bed. Resident was sent out for further medical evaluation and returned the same day with no new orders. A telephone appointment with the physician occurred on June 26, 2025. Resident will continue with Physical Therapy services and be administered pain medication as needed. Resident recently moved to Memory Care prior to the fall. Resident's care plan was updated recently and staff is proactively toileting resident more during the night to help prevent future falls. Resident (R3) had an unwitnessed fall on June 23, 2025 (4:30 pm) on the outside patio. Resident was sent out for further medical evaluation due to sustaining two skin tears on one arm and complaining of lower back pain. Resident returned the same day with no new orders. Resident will continue with Physical Therapy and Occupational Therapy and begin Home Health for wound care. Resident is doing fine currently. *cont on 809C-1.. 809C-1.. Resident (R4) was sent to the emergency room on June 17, 2025 due to their right ankle bleeding and blood pressure dropping. Resident returned the same day with a diagnosis of a hemorrhage and no new orders. Follow up appointments were scheduled with the physician (3) days later, in person, and by video in July. Resident currently takes blood thinners so bleeds easily. Resident is wearing a different kind of footwear that is more cushiony to help with thinning skin. The facility administrator stated there are Physical Therapy and Occupational Therapy services on site, and they are offered to all residents who have had a fall. Additionally, every fall is monitored and logged and discussed weekly with Assisted Living and Memory Care managers. The Administrator stated each fall is analyzed for the cause and what interventions have been implemented. The facility responded quickly and appropriately to each resident fall. There are no citations issued in this report. Exit interview. Copy of report provided.the state’s words, verbatim · CDSS document, Jul 1, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced an annual inspection and met with Marguerite Guerrero, Business Office Director and Mike Talani, Administrator, and explained purpose of inspection. The facility is licensed for 135 residents. Currently there are (33) residents in the Memory Care Unit, (73) residents in Assisted Living who are receiving services and (13) residents not on services. There are (6) residents under hospice care. There was live music entertainment in the afternoon. LPA and Administrator toured the interior of the facility including the common areas, main kitchen, gym, arts and crafts studio, sports bar, salon, theater, game room, physical therapy room and (4) resident rooms. In all areas toured, there were no health and safety concerns. Outside, there are several enclosed patios, a putting green, bocche ball and a pool that is gated/locked. There is 2+day perishable food and 7+day non-perishable food in the kitchen. Freezer/refrigerator temperatures are checked twice daily. Hot water temperatures were checked in (3) assisted living rooms and (1) memory care rooms. All temperatures measured within the 107-109*F range. Fire extinguishers were last serviced 4/11/25. All required postings are in the common areas. Disaster drills and other training is conducted monthly or as needed. LPA reviewed (10) resident files and (5) staff files. Files were organized, current and complete. Medications were reviewed for (1) resident and are being administered per orders. All staff is cleared/associated and is completing the required initial/ongoing training, including First Aid/CPR certifications. Vehicle service records reflect regular maintenance is scheduled/completed. Recent Dementia Care updates were added to the Plan of Operations. LPA obtained LIC500 and requested updated copy of insurance by 4/30/25. T here were no deficiencies observed. Exit interview. Copy of report provided to the Administrator.the state’s words, verbatim · CDSS document, Apr 23, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection related to several incident reports submitted to the Department. LPA met with Mike Talani, Administrator. LPA also met with Marie Valdiviezo, Resident Care Coordinator, and discussed (4) incident reports from March 2025. (R1) who fell on 3/6/25 began to receive home health services, including physical therapy to regain her strength.(R2) had a first fall on 3/19/25 and has returned to baseline. Many interventions were put into place. (R3) reported missing a ring in March 2025. The Ombudsman also investigated, and it was determined the ring was possibly lost at the hospital. (R4) reported missing cash but wasn't sure where the cash was when it disappeared. The police came out to investigate and was not able to conclude the cash was taken from (R4's room). The RCC stated all caregivers are great about reporting if a resident is missing an item. LPA observed both reported thefts to be documented per the facility's Theft and Loss policy. Additionally, training was provided by the Administrator and the Ombudsman regarding theft and loss and resident safeguarding their personal items following both reported incidents. There are no deficiencies issued in this report. Exit interview. Copy of report provided.the state’s words, verbatim · CDSS document, Apr 23, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection related to several incident reports received in the last few weeks. LPA met with Margarita Guerrero, Business Office Director, initially, and then Mike Talani, Administrator, Lance Ramos, Memory Care Director (MCD), and Nekia Xavier, LVN Health and Wellness Director (HWD). LPA stated the reason for the inspection. The following residents and incident reports were discussed, as follows: On 5/1/24, resident (R1) was found after an unwitnessed fall in her room on 4/23/24. Resident was sent to the emergency room (ER) due to observing a cut on her forehead. Resident was admitted to the hospital and received surgery for a left hip fracture. Resident was also diagnosed with a small brain bleed. Resident was independent in her care needs prior to this fall. HWD confirmed resident recently returned and is doing well. On 4/8/24, resident (R2) fell and sustained a scalp injury. Resident was sent out to the ER immediately and received two staples to her scalp, returning the same day. MCD stated resident is doing well and had the staples removed (10) days later. Resident has a pending order for physical therapy. On 4/14/24, resident (R3) had an unwitnessed fall in his room at 12:40 am, when trying to ambulate to the restroom. Resident would regularly refuse to use his walker, despite many staff, including the in-house physical therapist, encouraging the use of a walker. Prior to this fall, resident had completed a screening with the in-house Physical Therapist and was using the walker more often but was still seen to be ambulating without using one. Resident remains in skilled nursing and is participating in physical therapy until he is stronger to return to the community. On 4/16/24, resident (R4) was found on the floor in her room at 3:30 am and was transported to the ER for further medical evaluation. Resident returned on 4/18/24 with orders for PT, OT, Home Health and antibiotics. Resident will be evaluated if hospice care is appropriate. Resident has swelling in her legs and sometimes tries to get up her own without assistance from staff of a device. Resident's care plan updated. *cont on 809C-1... 809C-1... On 4/18/24, resident (R5) at 9:00 pm, was heard to scream while with care staff (S1) by Med-Tech staff (S2). Staff (S3), went to check on R5 and determined everything was okay. Resident was unable to explain why she screamed, due to a diagnosis of Dementia, but seemed agitated. S1 stated R5 was upset about having to transfer to the toilet. Resident was observed to have a small bruise or discoloration to the wrist and upper arm area on 4/19/24, but this was reported to managers on 4/22/24. The Administrator immediately pulled S1 off of the schedule and placed him on administrative leave; however, the staff member quit before any questions could be asked. The HWD, who is an LVN, assessed resident, and there were no complaints of signs of pain, but the red/yellow discoloration on resident's right forearm was noted. The Administrator stated that staff did not associate resident's scream to the bruising until a few days later, when it was reported. On 4/25/24, staff received training on resident abuse, mandated reported and the importance of timely reporting. The Ombudsman conducted a follow up visit and indicated the facility handled the situation appropriately, and there were no concerns. The police were called and a report number was provided. Additionally, resident's family and doctor were notified. Also discussed today was the non-hospice death, on 5/1/24, for resident (R6). MCD stated resident's death was totally unexpected by staff and the police promptly conducted an investigation and did not find anything concerning. MCD agreed to request a copy of the county death certificate and submit a copy to the Department. Also discussed today was resident's access to the gated/locked pool at the community. The Administrator stated Memory Care residents, or other residents with a diagnosis of Dementia, or MCI, will not have access to the pool. Also, any residents in ALU that are wanting to use the pool must check in with the lobby prior to use. The Administrator confirmed that the pool is always visible during staff rounds and provided a receipt for a new sign (ordered on 4/28/24) to replace the current sign that is faded stating there is "No Lifeguard on Duty", as requested by the insurance company. The Physical Therapist confirmed he has basic life support and CPR certification and he or another PT staff can get lifeguard safety/CPR, to be able to offer water aerobics classes. It appears the facility took appropriate action in sending residents out for emergency medical care in each situation and provided staff training when a medication documentation error was made. There are no deficiencies cited in this report. Exit interview. Copy of report provided to the Administrator.the state’s words, verbatim · CDSS document, May 2, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct an annual inspection and met with Marguerite Guerrero, Business Office Director and then Mike Talani, Administrator, and explained purpose of inspection. The facility is licensed for 135 residents. Currently there are (34) residents in the Memory Care Unit, (55) residents in Assisted Living who are receiving services and (30) residents not on services. There are (5) residents under hospice care. LPA and Administrator toured the interior of the facility including the common areas, main kitchen, gym, arts and crafts studio, sports bar, salon, theater, game room, physical therapy room and (2) resident rooms. In all areas toured, there were no health and safety concerns. Outside, there are several enclosed patios, a putting green, bocche ball and a pool that is gated/locked. LPA observed 2+day perishable food and 7+day non-perishable food in the kitchen. Freezer/refrigerator temperatures are checked twice daily. Hot water temperatures are checked weekly, throughout the facility- all temperatures recorded were within the 105-120*F. One delayed egress door was tested and found in working order. Fire extinguishers were last serviced 3/6/24. All required postings are in the common areas. RCFE Administrator certificate # 6039623740- exp 5/4/2024 is in the process of being renewed. LPA reviewed (10) resident files for Memory Care and (10) resident files for Assisted Living. All files contain current physician's reports and care plans and are complete with other required documentation. Medications were reviewed for (2) residents with Nekia Xavier, LVN Health and Wellness Director. Medications are being administered as ordered and documented in the QMAR. LPA reviewed (10) staff files. All staff is cleared/associated to the facility. All staff completes the required training through an approved on-line vendor and documentation was on file. LPA observed current First Aid/CPR documentation. Vehicle service were reviewed also on (2) vehicles. LPA requested that an updated copy of LIC500, LIC308 and current liability insurance be emailed by 4/11/24. There are no deficiencies issued during today's inspection. Exit interview. Copy of report provided to the Administrator.the state’s words, verbatim · CDSS document, Apr 4, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection and met with Nekia Xavier, LVN Health and Wellness Director, Mike Talani, Administrator, and Lance Ramos, Memory Care Director. LPA stated the reason for the inspection was to obtain additional information on several incident reports recently submitted to the Department. (R1) had an unwitnessed fall on 3/2/24 in her room and was sent to the hospital due to complaints of pain in her right leg/hip. Resident remained in the hospital until on/around 3/6/24 when she was transferred to a skilled nursing facility for physical therapy. Staff stated resident was not a fall risk and this was a first fall. Prior to resident returning, an updated care plan will be completed. (R2) was sent to the emergency room on 2/23/24 due to showing flu type symptoms. Resident had a pacemaker installed and was sent to a skilled nursing for rehab services following surgery. Resident will be reassessed prior to returning to the community and the care plan will be updated upon return. (R3) had a new medication order approved before the medications arrived. Staff inadvertently noted that the resident had received the medication when the resident had not. A note was later made in resident's file that the medication was not received, as indicated, and an in-service training was completed on correct medication documentation. This same medication was then discontinued 1-2 days later. (R4) was sent to the emergency room on 2/20/24 due to a wound on resident's right lower leg to appear to be worsening. Resident was treated for cellulitis and returned the same day to the community. Resident was receiving home health services and wound care treatment was added following the hospital stay. Resident was receiving assistance with showers prior to going to the hospital. Resident is being considered for hospice care due to other diagnoses. **cont on 809C 809C- (R5) had an unwitnessed fall on 2/21/24 in the dining room, sustaining some facial abrasions. Resident was sent to the emergency room and given antibiotics, returning the same day. Staff confirmed that resident was diagnosed with a UTI and an updated incident report was provided to LPA during today's inspection to include the hospital diagnosis. (R6) unexpectedly passed at the community on 3/4/24 and was not under hospice care. Facility staff stated there were no signs or symptoms indicating resident was going to pass soon, and resident was awake and alert with a Med-Tech a couple of hours before. Resident was also observed to be very active the day before. Resident had a diagnosis of acute respiratory failure, COPD and Hypertension and used oxygen on a regular basis and she was found using the oxygen concentrator when found non-responsive. The Sheriff came out and completed a report upon being notified of resident's passing. The Administrator agreed to request a copy of the county death certificate from resident's family and provide to the Department since resident was not under hospice care at the time of her passing. It appears the facility took appropriate action in sending residents out for emergency medical care in each situation and provided staff training when a medication documentation error was made. There are no deficiencies cited in this report. Exit interview. Copy of report provided to the Administrator.the state’s words, verbatim · CDSS document, Mar 6, 2024

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection and met with Margarita Guerrero, Business Office Director, explaining the purpose of today's inspection. LPA was informed there is an Interim Administrator at this time. LPA discussed an incident report submitted to the Department on 1/9/24 for an incident occurring on 1/5/24 for resident (R1). The incident report notes that (R1) had an unwitnessed fall in her room at approximately 10:00 am, complained of pain on her right shoulder and back and was immediately sent to the emergency room. (R1's) family member and primary care physician were promptly notified. (R1) was admitted to the hospital due to a fractured rib and will transfer to skilled nursing facility prior to returning to the community. The BOD indicated that just prior to falling on 1/5/24, (R1) had returned (2) days earlier from the hospital with a diagnosis of pneumonia and had begun taking antibiotics. File review confirms an updated physician's report was obtained on 12/31/23 and (R1) was treated for pneumonia. Additionally, the report notes (R1) is hard of hearing, can be confused but is able to follow directions and communicate. BOD indicated that (R1) was not a fall risk, liked to be independent, typically did not ask for assistance with ambulating inside her room, and is very alert and oriented to time/place. LPA reviewed (R1's) file and obtained a copy of the most current care plan dated 1/3/24. The care plan notes resident is independent with mobility/ambulation and only uses a cane to assist, does not require assistance with escorting, uses a pendant to request staff assistance, and has hearing impairment and anxiety, and receives caregiver checks 3 times daily, prior to each meal, for extra reminders. It appears the facility acted timely and appropriately in sending resident out for a further medication evaluation following the fall on 1/5/24. BOD stated that (R1) will be reassessed and an updated physician's report will be obtained prior to (R1) returning to the community. Also discussed were any Covid cases. There are no deficiencies issued in this report. Exit interview with BOD and copy of today's report provided.the state’s words, verbatim · CDSS document, Jan 11, 2024