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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496800457
Report Date: 09/09/2021
Date Signed: 09/09/2021 02:29:28 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
05/04/2021 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20210504152407
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:
09/09/2021
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Chey IlanTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff is not providing comfortable temperatures for resident
Staff are not meeting resident's dietary needs
Staff did not safeguard resident's personal belongings
Staff did not change resident's oxygen tank filter in a timely manner
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. Complainant alleges that R3 was often cold last winter, that staff are not providing food in satisfaction of R3's ordered diet, that facility did not safeguard R3's money. and that staff did not keep oxygen filters clean. During the course of this investigation, statements were taken from staff, witnesses, and residents; documents were reviewed; five unannounced site visits were made. The following determinations are made: Most residents stated that the facility is usually a comfortable temperature and at each site visit the facility temperature was within required range; Physician for Resident (R3) has prescribed a limited diet for R3 and facility has made reasonable effort to accommodate the diet; R3 often prefers to eat foods which do not meet the requirements; Money belonging to R3 has gone missing while R3 was in care, money amount was less that $100.00, was not reported for inventory, and R3 declined to report loss to law enforcement; There are varying opinions regarding the cleanliness of the oxygen filters; Service Technician for medical supply stated: "I did not observe any signs that the facility had neglected the equipment during the service calls I made." *** Continued on 9099(C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2021
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 5
Control Number 21-AS-20210504152407
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: 09/09/2021
NARRATIVE
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Although the allegations may be valid, or true, based upon the statements and observations made and records reviewed, there is not a preponderance of evidence to prove the allegations did or, did not, occur. Therefore, the allegations are UNSUBSTANTIATE.. Exit interview conducted and copy of report left at facility.
SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE:

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

DATE: 09/09/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
05/04/2021 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20210504152407

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:
09/09/2021
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Chey IlanTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff are not following the admissions agreement
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. Complainant alleges that Licensee asks residents to make rent checks payable to the Licensee and that this practice is in contradiction of the Admissions Agreement. A review of the Admissions agreement refutes the allegation and indicates method of payment as “cash, check, or money order,” and that “payment may be delivered to: Granada Manor.” Based upon statements made and records reviewed, the complaint is UNFOUNDED, meaning that the allegation is false, not true, and/or, without a reasonable basis. Therefore, the complaint is DISMISSED. Exit interview conducted and copy of report left at facility.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE:

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

DATE: 09/09/2021
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 5
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
05/04/2021 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20210504152407

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:
09/09/2021
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Chey IlanTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Facility ramp is in disrepair.
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. Complainant alleges that the railing for the front ramp is in disrepair. During the course of the investigation, five unannounced site visits were made as well as statements taken and records reviewed. During the site visit conducted on July 09, 2021, LPA observed that the front porch railing was loose. Licensee stated that the railing had been repaired but Licensee agreed to make further repairs. On subsequent site visits, LPA noted that the railing had been fully repaired and was functional. Based upon the statements and observations 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: 09/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20210504152407
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: 09/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/09/2021
Section Cited
CCR
87303(a)
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87303(a) Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times… ***This requirement has not been met as evidenced by: Based upon observations and statements made, the front porch railing is in disrepair in that the railing is

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Cleared at time of visit. Licensee has made repairs to the railing which is now fully functional.
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loose. This poses an immediate risk to the residents in care.

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

DATE: 09/09/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5