complaint·December 10, 2025

The investigation revealed the following: Allegation: Staff did not provide resident's authorized representative with an itemized list of charges It is alleged that the facility did not provide Resident 1's representative with an itemized list of additional care services at the time of admission. On 10/13/2025, between the hours of 11:15am - 12:09pm, LPA interviewed Administrator (A1) regarding the allegation. A1 neither confirmed nor denied the allegation. A1 stated based on the physician report determines how charges and extra care fees are explained and to the residents and their representative. A1 responded not applicable and did not provide the process. On 10/13/2025, between the hours of 9:04am - 1:00pm LPAs conducted interviews with Staff (S1-S9). 8 of 9 staff were unaware of the allegation as the caregivers have no knowledge of families being given itemized list of charges or a breakdown of extra care services. 1 of 9 staff did not confirm nor deny the allegation and S9 stated not generating the statement for invoices as that was the role of someone else who no longer works for the facility. However, Grandview does the billing for the residents. However, S9 stated its two care levels which is 17 (is when resident can still feed themselves, some in a wheelchair and ambulate) and level 22 (handfeeding, full care assist). S9 also stated R1 was level 22 because R1 couldn’t sit up without assistance and needed repositioning and transfers. On 10/13/2025 between the hours of 12:30pm - 12:45pm & on 12/03/2025 between the hours of 4:00pm -5:00pm, LPA conducted a records review and observed the following: receipts for care $7,200 - dated 07/28/2025 , for deposit (#4255) $500 - dated 07/25/2025, for deposit (#4258) $500 - dated 08/01/2025, for other half of pay (#4261) - $500 dated 08/09/2025, for September 2025 rent (#4267) $8,825. - dated 09/02/2025. Also based on Resident 1's Admission Agreement (signed on 07/29/2025) R1's room rate for a semi-private studio cost $5,000 with an additional miscellaneous care fee of $2,200 which comes to a total of $7,200. The review of the Admission Agreement does not itemize nor specify what the miscellaneous care service consist of nor rates of care services. LPA also review the invoices (statement dates 09/01/2025 and 10/01/2025). The review of both invoices show multiple dates and charges for room and board for $7200 and does not itemize the current months charges. Based on LPAs observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED under California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Report continues on LIC 9099-C The investigation revealed the following: Allegation: Resident's medical tube was pulled out due to staff neglect resulting in resident needing to go to the hospital. It is alleged that the facility failed to provide adequate supervision and medical care, resulting in the resident’s gallbladder (cholecystostomy) tube being pulled out on two separate occasions, which led to hospitalizations and infection. On 10/13/2025, between the hours of 11:15am - 12:09pm, LPA interviewed Administrator (A1) regarding the allegation. A1 denied the allegation. A1 stated Resident 1 (R1) did not have a g-tube and stated the resident was not on hospice nor receiving home health but was on Kaiser. On 10/13/2025, between the hours of 9:04am - 1:00pm, LPAs conducted interviews with Staff (S1-S8). 3 of 9 staff confirmed the allegation and stated by S2 observing R1 with a g-tube upon the partner of R1 informing staff that the g-tube was pulled out. S4 stated upon R1 first being at the facility he didn't have a g-tube but after the third time of R1 going to the hospital he returned to the facility with a g-tube. S8 stated R1 had a g-tube for 2-3 weeks which the caregiver did not know that R1 pulled out the g-tube himself. 1 of 9 staff denied the allegation and stated by S5 that R1 did not have a g-tube while residing at the facility. 3 of 9 staff were unaware of the allegation and stated having no knowledge of R1 having a g-tube. 2 of 9 staff didn't not confirm nor deny the allegation and stated upon admission resident never had a tube. However it was discovered R1 had some type gallbladder infestation which required him to have some kind of tube which he pulled out himself which isn't a g-tube. On 12/10/2025, the LPA conducted a records review and observed the following: In R1’s file, there was no documented care plan or approved exception request on file from the Department. The LPA observed a Kaiser Permanente discharge note dated 09/13/2025 indicating that R1 had a cholecystostomy tube. However, there was no documentation of a restricted health care plan or reappraisal related to the cholecystostomy tube. Additionally, the post-discharge plan of care did not document the presence of the cholecystostomy tube or the required care. Based on LPAs observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED under California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. An exit interview was conducted with Administrator Joel Niblett and a copy of this report was provided with appeal rights.