079200598-6-4-2024-15-AS-CFOR-D5WS5K-20240604133430

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200598
Report Date: 06/04/2024
Date Signed: 06/04/2024 01:34:44 PM

Document Has Been Signed on 06/04/2024 01:34 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 1		FACILITY NUMBER:	079200598
ADMINISTRATOR:	LI, FEI KEVIN		FACILITY TYPE:	740
ADDRESS:	2359 GRANADA COURT		TELEPHONE:	(510) 758-9888
CITY:	PINOLE	STATE: CA	ZIP CODE:	94564
CAPACITY:	6	CENSUS:	DATE:	06/04/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	FEI KEVIN LI, ADMINISTRATOR		TIME COMPLETED:	01:50 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 6/4/2024 at 9:30am, Licensing Program Analyst (LPA) Carol Fowler conducted an unannounced 1-Year Required inspection. LPA met with Fei Kevin Li, Administrator and explained the purpose of the visit. The Administrator currently holds a certificate (#6040792740) that expires on 07/26/2024. The facility’s fire clearance was approved for six (6) non-ambulatory residents. LPA toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area, garage and backyard. The facility consists of four (4) total bedrooms, which one (1) bedroom is occupied by staff, and two (2) bathrooms. No bodies of water observed. A comfortable temperature is maintained at 69 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 120 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 04/27/2023. Emergency Disaster Plan was last posted on 6/04/2024. First aid kit was observed to be complete. LPA reviewed three (3) staff files and all three (3) resident files which were all complete. Continued on LIC809C.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2024

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 06/04/2024 01:34 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 1	FACILITY NUMBER: 079200598
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

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. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having Pine-Sol in second bathroom unlocked on the sink which poses an immediate health and safety risk to persons in care.
	POC Due Date: 06/05/2024
	Plan of Correction
1 2 3 4	Administrator instructed caregiver to remove, lock and keep cleaning solutions locked at all times. DEFICIENCY CLEARED DURING VISIT.

Type A

Section Cited

CCR

87465(2)

87465 Incidental Medical and Dental Care (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by staff having unlocked medication in purse located in the living room and medication in room #3 in located in chest of drawers which poses an immediate health and safety risk to persons in care.
	POC Due Date: 06/05/2024
	Plan of Correction
1 2 3 4	Administrator instructed staff to remove and lock staff/all medications at all times. 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 Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/04/2024 01:34 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 1	FACILITY NUMBER: 079200598
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having refrigerator and freezer that needs to be cleaned which poses a potential health and safety risk to persons in care.
	POC Due Date: 06/12/2024
	Plan of Correction
1 2 3 4	Administrator agreed to clean the refrigerator and freezer and submit photos to CCLD by POC date.

Type B

Section Cited

CCR

87307(d)(4)

Personal Accommodations and Services

(4) Stairways, inclines, ramps and open porches and areas of potential hazard to residents with poor balance or eyesight shall be made inaccessible to residents unless equipped with sturdy hand railings and unless well-lighted. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having chair, sink, fan, box, walker 1/2 shovel, 2 ladders, night stand, mattresses, night stand, 2 lamps wheelchair, bookcase located in the backyard and open porch which poses a potential health and safety risk to persons in care.
	POC Due Date: 06/28/2024
	Plan of Correction
1 2 3 4	Administrator agreed to remove chair, sink, fan, box, walker 1/2 shovel, 2 ladders, night stand, mattresses, night stand, 2 lamps wheelchair, buckets, bookcase and submit photos to CCLD by the POC date.

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 Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/04/2024 01:34 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 1	FACILITY NUMBER: 079200598
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87305(a)

Prior to construction or alterations, all facilities shall obtain a building permit. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in having the shed in back yard fire cleared for staff living quarters which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/12/2024
	Plan of Correction
1 2 3 4	Administrator agreed to submit and LIC200 and updated facility sketch to CCLD by POC date

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2024

LIC809 (FAS) - (06/04)

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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
	VISIT DATE: 06/04/2024

NARRATIVE

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Continued from LIC809.

LPA observed the following deficiencies:

At 10:44am, LPA observed unlocked medication in staff bag located in the living room, and in room #3 in chest of drawers.
At 10:46am, LPA observed Pine-Sol in 2nd bathroom on sink.
At 10:56am, LPA observed freezer and refrigerator needs defrosting and cleaning.
At 10:58am, LPA observed chair, sink, fan, box, walker 1/2 shovel, 2 ladders, night stand, mattresses, night stand, 2 lamps wheelchair, buckets, bookcase located in the back yard and open porch.
Shed being used as living quarters/break room.

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

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

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2024

LIC809 (FAS) - (06/04)

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