Inspection Reports for Grandmother’s Crib
700 Sienna Station Way, Reno, NV 89512, NV, 89512
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Inspection Report
Annual Inspection
Census: 7
Capacity: 8
Deficiencies: 4
Jul 1, 2025
Visit Reason
The inspection was conducted as an annual State Licensure survey combined with a complaint investigation at the facility on 07/01/2025.
Findings
The facility received a grade of A with several deficiencies identified including incomplete first aid kit supplies, failure to obtain a general physical examination prior to admission for one resident, incorrect completion of Standard Physician Assessment and Placement Determinations (PAPD) for six residents, and failure of the secondary infection control manager to complete required annual infection control training.
Complaint Details
One complaint (#NV00071283) was investigated with allegations including mold presence, posting of resident's private information, and caregiver file documentation deficiencies. The complaint was not substantiated due to lack of evidence.
Severity Breakdown
Level 2: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility failed to maintain the contents of a first aid kit, missing a CPR shield/mask, adhesive bandages, and a thermometer. | Level 2 |
| Facility failed to obtain the results of a general physical examination for 1 of 7 residents prior to admission (Resident #4). | Level 2 |
| Facility failed to ensure appropriate Standard Physician Assessment and Placement Determinations (PAPD) were completed correctly for 6 of 7 residents. | Level 2 |
| Facility failed to ensure the secondary infection control manager (Employee #5) completed 15 hours of infection control training annually. | Level 2 |
Report Facts
Residents files reviewed: 7
Employee files reviewed: 5
Caregivers scheduled: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| EVA BELTEJAR | owner | Signed as Laboratory Director's or Provider/Supplier Representative. |
| Employee #5 | Caregiver and secondary infection control manager | Named in deficiency for failure to complete required infection control training. |
Inspection Report
Annual Inspection
Census: 8
Capacity: 8
Deficiencies: 4
Sep 3, 2024
Visit Reason
This inspection was conducted as an annual State Licensure survey of the facility on 09/03/2024 by the Division of Public and Behavioral Health in accordance with NAC 449 for Residential Facility for Groups.
Findings
The facility received a grade of A. Deficiencies were identified related to caregiver medication management training, tuberculosis screening for employees, missing window screens for ventilation, and incomplete first aid kit contents. Corrective actions and plans of correction were implemented for each deficiency.
Severity Breakdown
Severity: 2: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility failed to ensure 1 of 4 employees completed the required sixteen hours of initial medication management training. | Severity: 2 |
| Facility failed to ensure a tuberculosis (TB) screening was completed for 1 of 4 employees. | Severity: 2 |
| Facility failed to ensure all windows capable of being opened were screened to prevent entry of insects; two windows lacked screens. | Severity: 2 |
| Facility failed to maintain the contents of a first aid kit; missing CPR mask, germicide, and thermometer. | Severity: 2 |
Report Facts
Residents present: 8
Total licensed capacity: 8
Employees reviewed: 4
Resident files reviewed: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #4 | Caregiver | Named in medication management training deficiency |
| Employee #1 | Administrator | Named in tuberculosis screening deficiency |
| EVA BELTEJAR | Owner | Facility owner involved in confirming deficiencies and corrective actions |
Inspection Report
Original Licensing
Capacity: 6
Deficiencies: 0
Nov 14, 2023
Visit Reason
The inspection was conducted as a State Licensure bed increase survey to approve the facility's request for two additional Residential Facility for Group beds for elderly and disabled persons and/or persons with mental illnesses, Category II residents.
Findings
The bed increase application was approved. Deficiencies identified at the time of survey were corrected, and no further action was necessary.
Report Facts
Licensed beds before increase: 6
Additional beds requested: 2
Inspection Report
Annual Inspection
Census: 5
Capacity: 6
Deficiencies: 2
Jul 18, 2023
Visit Reason
The inspection was conducted as a State Licensure survey for a Residential Facility for Groups to assess compliance with NAC 449 regulations.
Findings
The facility received a grade of A with deficiencies noted related to exterior premises cleanliness and maintenance, including a hazardous vanity mirror left on a walkway and burnt-out light bulbs, as well as failure to complete an annual Activities of Daily Living (ADL) assessment for one resident.
Severity Breakdown
Severity: 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| The facility failed to ensure the exterior premises were clean and maintained, including a large vanity mirror left on the walkway and burnt-out light bulbs in the resident bathroom. | Severity: 2 |
| The facility failed to ensure annual Activities of Daily Living (ADL) assessments were completed for one resident as required. | Severity: 2 |
Report Facts
Licensed beds: 6
Resident census: 5
Resident files reviewed: 5
Employee files reviewed: 4
Inspection Report
Re-Inspection
Census: 5
Capacity: 6
Deficiencies: 9
Jan 25, 2023
Visit Reason
This inspection was a grading re-survey State Licensure survey conducted to evaluate compliance with NAC 449 for a Residential Facility for Groups.
Findings
No regulatory deficiencies were identified during this re-survey. The facility received a grade of A and no further action was necessary.
Severity Breakdown
F: 3
E: 1
D: 4
C: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Personnel Files - Background Checks - NAC 449.200 Personnel files must include evidence of compliance with NRS 449.122 to 449.125. | F |
| First Aid & CPR - NAC 449.231 requires administrators or caregivers to be trained in first aid and CPR within 30 days of employment. | E |
| Rights of Residents; Procedure for Filing - NAC 449.268 requires the facility to ensure a safe and comfortable environment. | F |
| Medical Care of Resident After Illness - NAC 449.274 requires periodic physical examinations and adherence to physician instructions. | D |
| Medication Education Initial/Annual Administrator - NAC 449.2742 requires administrators to receive initial and annual training in medication management. | D |
| Administration of Medication Maintenance - NAC 449.2744 requires maintenance of medication records including type, date/time administered, refusals, and instructions. | D |
| Placard - Display - NAC 449.27704 requires the administrator to display the placard conspicuously within 24 hours of receipt. | C |
| Cultural Competency Training | F |
| Preferred Name/Pronoun Policies and Procedures | D |
Report Facts
Licensed beds: 6
Resident census: 5
Employee files reviewed: 4
Resident files reviewed: 5
Grade received: A
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 9
Jul 18, 2022
Visit Reason
This inspection was an annual State Licensure survey conducted to assess compliance with NAC 449 for Residential Facility for Groups.
Findings
The facility received a grade of D with multiple deficiencies identified including incomplete background checks for employees, lack of first aid training, missing annual fit testing for N-95 respirators, incomplete physical examinations for residents, medication administration errors, failure to display the latest survey placard, and lack of cultural competency training and policies.
Severity Breakdown
F: 3
E: 1
D: 4
C: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to ensure 3 of 4 employees met background check requirements including fingerprints and clearance letters. | F |
| Failed to ensure 2 of 4 employees maintained first aid training and certification. | E |
| Failed to have appropriate annual fit testing and clearance for at least one caregiver to wear an N-95 respirator. | F |
| Failed to ensure a physical examination including review of systems was completed on or prior to admission for 1 of 6 residents. | D |
| Failed to ensure 1 of 4 employees completed required eight hours of annual medication management training. | D |
| Failed to ensure a physician order was obtained for a medication administered for 1 of 6 residents. | D |
| Failed to conspicuously display the letter grade placard from the last annual State Licensure survey. | C |
| Failed to ensure employees received cultural competency training within 30 days of hire for 4 of 4 employees. | F |
| Failed to develop policies addressing the facility's program for cultural competency. | D |
Report Facts
Licensed beds: 6
Current census: 6
Grade: D
Fee for resurvey application: 600
Number of employee files reviewed: 4
Number of resident files reviewed: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Evangeline Beltejar-Difuntorum | Owner | Signed the inspection report and is referenced as Owner/Caregiver confirming findings |
| Employee #2 | Administrator | Named in deficiencies related to background checks, first aid training, medication management training |
| Employee #3 | Owner/Caregiver | Named in deficiencies related to background checks, first aid training, cultural competency training |
| Employee #4 | Caregiver | Named in deficiencies related to background checks, cultural competency training |
| Employee #1 | Caregiver | Named in deficiencies related to cultural competency training |
Inspection Report
Annual Inspection
Census: 4
Capacity: 6
Deficiencies: 1
Jul 22, 2021
Visit Reason
The inspection was conducted as an annual State Licensure survey of the facility to assess compliance with regulations for Residential Facility for Groups.
Findings
The facility received a grade of A; however, a deficiency was identified related to missing window screens on multiple windows, which failed to prevent insect entry.
Severity Breakdown
2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure all windows and doors had screens to prevent entry of insects, with multiple window screens missing on the backyard side including living room and a resident's room. | 2 |
Report Facts
Resident files reviewed: 4
Employee files reviewed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Evangeline Beltejar | Owner | Owner verbalized understanding of missing window screens and need for installation |
Inspection Report
Follow-Up
Census: 5
Capacity: 6
Deficiencies: 0
Oct 12, 2020
Visit Reason
This inspection was a follow-up State Licensure COVID-19 Infection Control and Prevention Plan Survey conducted to assess the facility's compliance with infection control measures.
Findings
The facility maintained appropriate COVID-19 infection control practices including visitor screening, use of PPE, social distancing, and cleaning protocols. No regulatory deficiencies were identified during this follow-up survey.
Report Facts
Facility licensed beds: 6
Resident census: 5
Inspection Report
Routine
Census: 5
Capacity: 6
Deficiencies: 0
Sep 21, 2020
Visit Reason
This inspection was conducted as a State Licensure COVID-19 Infection Control and Prevention Plan Survey to assess the facility's compliance with infection control requirements.
Findings
No regulatory deficiencies were identified; however, the facility did not have a documented Infection Control and Prevention Plan. Resources were provided and the Administrator committed to having a plan ready for follow-up by 10/05/20.
Report Facts
Licensed beds: 6
Census: 5
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 1
Jul 14, 2020
Visit Reason
This inspection was conducted as an annual State Licensure survey of the facility in accordance with NAC 449 for Residential Facility for Groups.
Findings
The facility received a grade of A. One deficiency was identified related to the late annual tuberculosis (TB) testing for one employee (Employee #3). The facility has since taken corrective action to complete the required TB testing.
Severity Breakdown
2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 4 employee's annual tuberculosis (TB) testing requirements was available for review during survey; Employee #3's 2020 TB test was late and should have included a two-step test. | 2 |
Report Facts
Number of resident files reviewed: 6
Number of employee files reviewed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Evangeline Beltejar | Owner | Acknowledged the late TB test for Employee #3 and confirmed testing requirements |
Inspection Report
Annual Inspection
Census: 4
Capacity: 6
Deficiencies: 3
Jan 4, 2016
Visit Reason
The inspection was conducted as an annual State Licensure survey of a residential facility for elderly and disabled persons and/or persons with mental illnesses.
Findings
The facility received a grade A. Deficiencies were identified related to personnel background checks, fire alarm system compliance, and physical examinations of residents.
Severity Breakdown
Severity: 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure 3 of 3 employees met background check requirements as evidenced by missing or outdated background check documentation. | Severity: 2 |
| Failure to ensure the fire alarm system was in compliance with State Fire Marshall regulations; a trouble light was observed on the fire alarm panel. | Severity: 2 |
| Failure to ensure 1 of 4 residents received a physical prior to admission or annual physical as required. | Severity: 2 |
Report Facts
Census: 4
Total Capacity: 6
Deficiency Scope: 3
Deficiency Scope: 3
Deficiency Scope: 1
Inspection Report
Annual Inspection
Census: 4
Capacity: 6
Deficiencies: 3
Jan 4, 2016
Visit Reason
This inspection was conducted as an annual State Licensure survey to assess compliance with state regulations for a Residential Facility for Group beds for elderly and disabled persons.
Findings
The facility received a grade of A but had deficiencies including failure to ensure background checks for 3 employees, non-compliance with fire alarm system inspections, and lack of annual physical examination documentation for 1 resident.
Severity Breakdown
2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure 3 of 3 employees met background check requirements of NRS 449. | 2 |
| Failed to ensure the fire alarm system was in compliance with State Fire Marshal regulations regarding inspections; system trouble light and buzzing sound observed. | 2 |
| Failed to ensure 1 of 4 residents received a physical prior to admission or an annual physical. | 2 |
Report Facts
Number of residents: 4
Licensed capacity: 6
Number of employee files reviewed: 3
Number of resident files reviewed: 4
Severity level 2 deficiencies: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employees #1, #2, and #3 referenced in background check deficiency without full names | ||
| Employee #2 confirmed missing documentation and awareness of fire alarm issue |
Inspection Report
Annual Inspection
Census: 3
Capacity: 6
Deficiencies: 0
Dec 18, 2014
Visit Reason
The inspection was an annual State Licensure survey conducted by the Division of Public and Behavioral Health to assess compliance with licensing requirements.
Findings
No deficiencies were identified during the survey. The facility received a grade of A after review of three resident files and three employee files.
Inspection Report
Annual Inspection
Census: 3
Capacity: 6
Deficiencies: 0
Dec 18, 2014
Visit Reason
This document is the result of an annual State Licensure survey conducted at the facility on 12/18/2014 to assess compliance with state regulations for a Residential Facility for Group beds for elderly and disabled persons and/or persons with mental illness.
Findings
The facility was found to be in full compliance with no deficiencies identified and received a grade of A.
Report Facts
Licensed beds: 6
Resident census: 3
Inspection Report
Complaint Investigation
Census: 5
Capacity: 6
Deficiencies: 1
Mar 19, 2014
Visit Reason
The inspection was conducted as a complaint investigation from 3/6/14 through 3/19/14 based on Complaint #NV00038157, which contained allegations of quality of care by an unqualified caregiver and resident abuse by an employee.
Findings
The investigation substantiated the allegation of an unqualified caregiver under 18 years assisting with resident care, but found no evidence of resident abuse. The facility was clean and residents were observed in good condition. The unqualified caregiver was a 17-year-old who occasionally assisted with resident activities of daily living.
Complaint Details
Complaint #NV00038157 contained two allegations: 1) Quality of Care/Treatment: unqualified caregiver (substantiated). 2) Resident abuse: employee to resident (unsubstantiated).
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility allowed an unqualified caregiver under the age of 18 years to assist with resident activities of daily living. | Severity: 2 |
Report Facts
Licensed capacity: 6
Census: 5
Severity level: 2
Scope: 3
Inspection Report
Complaint Investigation
Census: 5
Capacity: 6
Deficiencies: 1
Mar 11, 2014
Visit Reason
The inspection was conducted as a result of a complaint investigation from 03/06/14 through 03/19/14 regarding allegations of unqualified caregiver and resident abuse at the facility.
Findings
The investigation substantiated the allegation of an unqualified caregiver under the age of 18 assisting with resident care, but found no evidence of verbal abuse towards Resident #1. The facility was clean and residents were observed in good condition.
Complaint Details
Complaint #NV00038157 contained two allegations: 1) Quality of Care/Treatment: unqualified caregiver (substantiated), 2) Resident abuse: employee to resident (unsubstantiated).
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility allowed an unqualified caregiver under the age of 18 to assist with resident activities of daily living. | Severity: 2 |
Report Facts
Census: 5
Total Capacity: 6
Complaint Number: Complaint #NV00038157
Inspection Report
Annual Inspection
Census: 4
Capacity: 6
Deficiencies: 4
Oct 3, 2013
Visit Reason
This document is a State Licensure annual grading survey conducted from 9/24/2013 to 10/3/2013 to assess compliance with state regulations for a residential facility for elderly and disabled persons.
Findings
The facility received a grade of A but had several deficiencies including missing tuberculosis testing documentation for one employee, incomplete background checks for two employees, failure to indicate medication changes on containers for one resident, and inaccuracies in medication administration records for three residents.
Severity Breakdown
Severity: 2: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 4 employees complied with tuberculosis testing requirements (missing pre-employment physical exam, chest X-ray, and TB sign and symptoms form). | Severity: 2 |
| Failed to ensure 2 of 4 employees met background check requirements (missing State and FBI background checks). | Severity: 2 |
| Failed to indicate on the container of medication that a change had occurred for 1 of 4 residents (Trazadone and Lorazepam). | Severity: 2 |
| Medication administration record was inaccurate for 3 of 4 residents inspected, including missing signatures and incomplete directions. | Severity: 2 |
Report Facts
Number of residents present: 4
Total licensed capacity: 6
Number of employees reviewed: 4
Number of resident files reviewed: 4
Inspection Report
Annual Inspection
Census: 4
Capacity: 6
Deficiencies: 5
Sep 24, 2013
Visit Reason
This document is a State Licensure annual grading survey conducted from 09/24/2013 to 10/03/2013 at Grandmother's Crib, a residential facility for elderly and disabled persons.
Findings
The facility received a grade of A. Several deficiencies were identified related to personnel files, tuberculosis testing, background checks, medication administration, and documentation accuracy.
Severity Breakdown
1: 1
2: 4
Deficiencies (5)
| Description | Severity |
|---|---|
| Personnel file missing pre-employment physical exam, chest X-ray, and TB sign and symptoms form for Employee #4. | 2 |
| Personnel file missing State and FBI background checks for Employees #2 and #4. | 2 |
| Failure to indicate on medication containers that a change had occurred for 1 of 4 residents. | 2 |
| Failure to include over-the-counter medications/dietary supplements on medication administration records for residents. | 1 |
| Medication administration records inaccurate or incomplete for 3 of 4 MARs inspected, including missing signatures and directions. | 2 |
Report Facts
Number of employees reviewed: 4
Number of resident files reviewed: 4
Facility licensed capacity: 6
Current census: 4
Inspection Report
Complaint Investigation
Capacity: 6
Deficiencies: 1
Apr 12, 2013
Visit Reason
This State Licensure survey was conducted as a result of a complaint investigation regarding the facility.
Findings
The administrator failed to ensure residents were treated with respect and dignity, as substantiated by the complaint. Cameras were found in all residents' bedrooms without proper authorization, violating resident rights.
Complaint Details
Complaint #NV00034796 was substantiated. Based on a report from Aging and Disability Services Division (ADSD) Ombudsman (OMB) on 2/22/13, the administrator failed to ensure residents were treated with respect and dignity. OMB found cameras in all residents' bedrooms and caregivers confirmed the manager placed cameras to monitor residents without proper consent.
Severity Breakdown
Severity 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure residents were treated with respect and dignity, including unauthorized cameras in residents' bedrooms. | Severity: 2 |
Report Facts
Total licensed capacity: 6
Severity level: 2
Scope: 3
Inspection Report
Complaint Investigation
Capacity: 6
Deficiencies: 1
Apr 12, 2013
Visit Reason
This inspection was conducted as a result of a complaint investigation regarding the facility, specifically complaint #NV00034796.
Findings
The investigation found that the administrator failed to ensure residents were treated with respect and dignity, evidenced by the presence of cameras in all residents' bedrooms without resident authorization.
Complaint Details
Complaint #NV00034796 was substantiated. The complaint involved unauthorized cameras in residents' rooms, confirmed by caregivers and a resident who stated they were not asked for authorization.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Administrator failed to ensure residents were treated with respect and dignity due to unauthorized cameras in residents' bedrooms. | Severity: 2 |
Report Facts
Total licensed beds: 6
Severity level: 2
Scope: 3
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