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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200359
Report Date: 07/27/2023
Date Signed: 07/27/2023 12:22:33 PM

Document Has Been Signed on 07/27/2023 12:22 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:GRANGER CARE HOMEFACILITY NUMBER:
019200359
ADMINISTRATOR:PERLA V. GARCIAFACILITY TYPE:
735
ADDRESS:30751 GRANGER AVENUETELEPHONE:
(510) 972-0954
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 6DATE:
07/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Teresita Cruz, LicenseeTIME COMPLETED:
12:35 PM
NARRATIVE
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On this day at around 8:50 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct an annual required inspection and met with Licensee Teresita Cruz. LPA explained to Cruz the purpose of the visit. The facility is a Level 4C home vendored by the Regional Center of the East Bay (RCEB).

LPA inspected the facility inside and out including but not limited to client bedrooms, bathrooms, kitchen, dining area, backyard and living area. There was sufficient lighting throughout the facility. No bodies of water were observed. There was sufficient supply of perishable and non-perishable foods. Sufficient blankets, sheets, towels, hand towels were observed. Fire extinguisher in the kitchen area was observed to be full and last inspected on 9/22/2022. First aid kit was observed complete and updated. Smoke detector and carbon monoxide were tested and observed operational.

Last fire and earthquake drills were done on July 15, 2023. At around 9:25 am, LPA reviewed P&I money and log. The facility has sufficient amount of surety bond ($5,000) to cover amount of money being handled at one time.

At 9:50 am, LPA reviewed 5 client files and 5 staff files.

At 9:09 am, LPA observed hot water measured at 124.4 degrees Fahrenheit.

Deficiencies are cited per Title 22 California Code of Regulations (refer to Lic 809D).

Exit interview was conducted and Appeal Rights was provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
Document Has Been Signed on 07/27/2023 12:22 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 07/27/2023 at 11:47 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: GRANGER CARE HOME
FACILITY NUMBER: 019200359

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having hot water at 124.4 degrees Fahrenheit which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/27/2023
Plan of Correction
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Staff adjusted hot water to 118 Fahrenheit during the visit. Deficiency is cleared.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2023


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 07/27/2023 12:22 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 07/27/2023 at 11:47 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: GRANGER CARE HOME
FACILITY NUMBER: 019200359

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(b)(1)(A)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (1) In adult CCFs, facility staff who receive training may assist clients with metered-dose inhalers, and dry powder inhalers if the following requirements are met: (A) In ARFs, facility staff must recieve training from a licensed proessional.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation and record review, the licensee did not comply with the section cited above in not having proof of training from licensed professional which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/08/2023
Plan of Correction
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By POC date, Administrator will submit proof of training to CCL.
Type B
Section Cited
CCR
80075(b)(1)(A)1
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (1) In adult CCFs, facility staff who receive training may assist clients with metered-dose inhalers, and dry powder inhalers if the following requirements are met: (A) In ARFs, facility staff must recieve training from a licensed proessional. 1. The licensee shall obtain written documentation from the licensed professional outlining the procedures and the names of facility staff who have been trained in those procedures.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview conducted, the licensee did not comply with the section cited above in not having written documentation from licensed professional procedures and names of staff who have been trained which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/08/2023
Plan of Correction
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By POC date, Administrator will submit to CCL procedures and names of staff trained by a licensed professional.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 07/27/2023 12:22 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 07/27/2023 at 11:47 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: GRANGER CARE HOME
FACILITY NUMBER: 019200359

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(b)(1)(A)2
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (1) In adult CCFs, facility staff who receive training may assist clients with metered-dose inhalers, and dry powder inhalers if the following requirements are met: (A) In ARFs, facility staff must recieve training from a licensed proessional. 2. The licensee ensures that the licesned professional reviews staff performance as the licensed professional deems necessary, but at least once a year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observtion, the licensee did not comply with the section cited above in not having licensed professional review staff performance.... which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/08/2023
Plan of Correction
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By POC date, Administrator will submit to CCL a review of staff performance in administering inhaler to client.
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2023


LIC809 (FAS) - (06/04)
Page: 4 of 4