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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200598
Report Date: 05/20/2022
Date Signed: 05/20/2022 11:10:29 AM


Document Has Been Signed on 05/20/2022 11:10 AM - 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 1FACILITY NUMBER:
079200598
ADMINISTRATOR:LI, FEI KEVINFACILITY TYPE:
740
ADDRESS:2359 GRANADA COURTTELEPHONE:
(510) 758-9888
CITY:PINOLESTATE: CAZIP CODE:
94564
CAPACITY:6CENSUS: 6DATE:
05/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Fei Kevin LiTIME COMPLETED:
11:15 AM
NARRATIVE
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On 5/20/2022 at 9:00 am, Licensing Program Analyst (LPA) C. Fowler arrived unannounced to conduct an Infection Control Inspection. LPA met with Administrator, Fei Kevin Li and Caregiver Reggielyn Daigdigan and explained the purpose of the visit. Administrator had to leave and approved Caregiver to sign documents.

Upon entry, LPA observed screening station that contained hand sanitizer, thermometer and COVID-19 signage. LPA toured facility including but not limited to common areas, bathrooms, bedrooms, kitchen, and backyard. LPA observed cough etiquette and physical distancing posted in the common areas. All hand washing stations were equipped with soap, paper towel, and hand washing posters.

During record review, LPA observed visitors log and temperature logs for residents or staff. LPA observed facility has a copy of Mitigation Plan on file.

The following deficiencies were observed during the visit:

-At 9:14am, LPA observed All-Purpose cleaner under an unlocked sink in the bathroom.
-At 9:18am, LPA observed scissors in a unlocked drawer in the kitchen.
-At 9::20am, LPA observed screen door, lamp, chairs, flag, fan boxes located in the backyard.
-At 9:21am, LPA observed used oxygen tanks, bed rails, wood planks located in the backyard.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies by POC date may result in additional Civil Penalties.

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: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/20/2022 11:10 AM - 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 1
FACILITY NUMBER: 079200598

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(1)(a)
87309(a)(1)

(1) 87309 Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. Storage areas for poisons... shall be locked.This requirement was not met as evidence by

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 by having All-Purpose cleaner stored in an unlocked cabinet in the bathroom which poses an immediate health and safety risk to persons in care.
POC Due Date: 05/21/2022
Plan of Correction
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Administrator removed All-Purpose cleaner during visit. Deficiency cleared during visit.
Type A
Section Cited
CCR
87705(f)(1)
87705 Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia:

(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

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 by having scissors in an unlocked drawer in the kitchen which poses an immediate health and safety risk to persons in care.
POC Due Date: 05/21/2022
Plan of Correction
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Administrator locked the scissors. Deficiency cleared during visit.

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: 05/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 05/20/2022 11:10 AM - 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 1
FACILITY NUMBER: 079200598

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation 87303(a)

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.


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 by having screen door, lamp, chairs, flag, fan boxes, oxygen tanks, wood planks bed rails accessiable to residents in care which poses a potential health and safety risk to persons in care.
POC Due Date: 05/27/2022
Plan of Correction
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Administrator agreed to remove all items above and provide CCLD with photo copies no later than the POC date.
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: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 05/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3