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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200596
Report Date: 09/26/2024
Date Signed: 09/26/2024 02:55:48 PM


Document Has Been Signed on 09/26/2024 02:55 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:GRANADA CARE HOME NO 2FACILITY NUMBER:
079200596
ADMINISTRATOR:LI, FEI KEVINFACILITY TYPE:
740
ADDRESS:2360 GRANADA COURTTELEPHONE:
(510) 758-9888
CITY:PINOLESTATE: CAZIP CODE:
94564
CAPACITY:6CENSUS: 4DATE:
09/26/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:FEI KEVIN LI, ADMINISTRATORTIME COMPLETED:
03:20 PM
NARRATIVE
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On 09/26/2024 at 01:25 PM Licensing Program Analysts (LPAs), Carol Fowler and David Doidge arrived unannounced to conduct a 10 day initial complaint visit (15-AS-20240919144934).

Upon LPAs arrived LPA Carol Fowler saw a pill in a kitchen chair, S1 stated S1 didn't know how long the pill was there and did not know who the pill belong to.

Regulation are cited from California Code of Regulations, Title 22, are being cited on the attached LIC809D. Therefore, this allegation is Substantiated.

Exit interview conducted. A copy of this report and appeal rights provided.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2024
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 2


Document Has Been Signed on 09/26/2024 02:55 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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


FACILITY NAME: GRANADA CARE HOME NO 2
FACILITY NUMBER: 079200596

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/27/2024
Section Cited
CCR
87465(h)(2)

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(h) The following requirements shall apply to medications which are centrally stored:
(2) Centrally stored medicines sha... place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication
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Administrator agreed to keep all medication locked at all times. Staff removed medication during visit. DEFICIENCY CLEARED DURING VISIT.
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Based on observation, the licensee did not comply with the section cited above. LPA observed unlocked pill on a chair located in the kitchen which poses an immediate health risk to persons 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.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2