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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496800457
Report Date: 09/02/2021
Date Signed: 09/02/2021 02:13:46 PM

Unsubstantiated


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
05/24/2021 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20210524151058
FACILITY NAME:GRANADA MANORFACILITY NUMBER:
496800457
ADMINISTRATOR:ILAN, CHEYFACILITY TYPE:
740
ADDRESS:4760 GRANADA DR.TELEPHONE:
(707) 539-7059
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY:6CENSUS: 6DATE:
09/02/2021
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Chey IlanTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff engaged into a verbal argument with a resident while in care
Staff engaged into a physical altercation with a resident while in care
Staff are sleeping during the evening shift
Residents are left soiled for extended periods of time
Staff are interfering with residents eating schedules
INVESTIGATION FINDINGS:
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Licensing Program analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. LPA met with ****and discussed the findings. During the course of the investigation, statements were taken and documents reviewed, as well as four site visits made. The following determinations are made: Santa Rosa Police were dispatched to the facility on May 22, 2021 in response to a report of elder abuse following an incident alleging a staff person was verbally and physically abusive to a resident. When interviewed, Reporting Party made additional allegations as enumerated in above captioned allegations. Investigating Officer found that residents were in apparent good health and no indication of abuse or neglect. This Department followed up by conducting unannounced visits and interviewing residents and staff. All but one resident was interviewed and each stated that the staff was caring and that they were treated well. There was agreement that residents were satisfied with the food and meal time routines; that alert staff were on duty at night to assist residents with bathroom trips or changing. There are differing opinions as to whether or not a staff person was verbally or physically abuse to a resident on 5/22, although Police found no evidenced of abuse. **Continued on second page.***
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021
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 4
Control Number 21-AS-20210524151058
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: GRANADA MANOR
FACILITY NUMBER: 496800457
VISIT DATE: 09/02/2021
NARRATIVE
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Although the allegations may be true, based upon statements and observations, there is not a preponderance of evidence to prove the allegations did, or did not, occur. Therefore, the allegations are UNSUBSTANTIATED.
SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
05/24/2021 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20210524151058

FACILITY NAME:GRANADA MANORFACILITY NUMBER:
496800457
ADMINISTRATOR:ILAN, CHEYFACILITY TYPE:
740
ADDRESS:4760 GRANADA DR.TELEPHONE:
(707) 539-7059
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY:6CENSUS: 6DATE:
09/02/2021
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Chey IlanTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff are forcing residents to sleep
INVESTIGATION FINDINGS:
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Licensing Program analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. LPA met with Chey Ilan and discussed the findings. During the course of the investigation, statements were taken and documents reviewed, as well as four site visits made. The following determinations are made: During the course of site visits made to the facility during the course of this investigations, all but one resident was interviewed about the night time routine and bedtime. With no exception, residents state that they are told to go to bed at 8:00 or 8:30 each night; some residents object to the bedtime, although most are not objecting. Based upon the statements made, the preponderance of evidence standard has been met. Therefore, the allegation is SUBSTANTIATED. The following deficiencies were observed (see LIC 9099D) 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.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021
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 4
Control Number 21-AS-20210524151058
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: GRANADA MANOR
FACILITY NUMBER: 496800457
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/06/2021
Section Cited
CCR
87468.1(a)(1)
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87468.1(a)(1) PERSONAL RIGHTS OF RESIDENTS. Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1)To be accorded dignity in their personal relationships with staff, residents, and other persons.

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Administrator shall immediately cease the practice of requiring residents to retire at 8:00 or 8:30 at night and will train staff in the requirements of 87468 regulation. Any proposed rules or schedules addressing resident bedtimes or evening schedules should be submitted to CCL in proposal form as a requested amendment to the


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 ***Based upon statements made, this requirement has not been met as evidenced by: Residents state that the residents are told to go to bed at 8:00 or 8:30 each night by staff. This is an immediate violation of the residents’ personal rights.

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Program Plan. Staff training proof to be submitted by POC date in order to clear the deficiency.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4