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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610291
Report Date: 10/08/2024
Date Signed: 10/08/2024 02:25:28 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 10/08/2024 02:25 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:GRANVILLE RESIDENTIAL CAREFACILITY NUMBER:
197610291
ADMINISTRATOR/
DIRECTOR:		SCOTT, SONYAFACILITY TYPE:
735
ADDRESS:1656 GRANVILLE WAYTELEPHONE:
(562) 316-7038
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 4CENSUS: 0DATE:
10/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Renwick MixonTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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On 10/08/2024 Licensing Program Analyst (LPA) Lorena Casillas arrived at facility for an unannounced one (1) year Required visit for this facility.

LPA Casillas arrived at 12:00 pm, LPA was able to speak to Administrator and was told they would be designating Renwick Mixon to sign the report. LPA explained the reason for the visit and entrance interview was conducted.

A tour of the physical plant was conducted with designee at 12:30 pm. The facility has four (4) bedrooms and four (4) bathrooms currently occupying no clients. The tool kit was not used on this visit as there are no clients.

Infection control: LPA Casillas reviewed the facility Infection Control Plan submitted on 12/08/2022 to make sure protocols are being followed.

Living and dining: At 12:40 pm, LPA observed the living room and family room area to be neat and clean along with the dining room. LPA observed the locked medication cabinet for extra medications and client files. The facility maintains a comfortable temperature at 74°F. There is one (1) fire extinguisher located in the kitchen and one (1) fire extinguisher in the hallway, last purchased on 02/05/2024. The carbon monoxide detector and smoke detector were tested and observed to be operational at 12:45 pm. Medications and first aid kit are also locked in a cabinet in dining area.

Continued on LIC809-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE: DATE: 10/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/08/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: GRANVILLE RESIDENTIAL CARE
FACILITY NUMBER: 197610291
VISIT DATE: 10/08/2024
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Kitchen: LPA conducted a tour of the kitchen around 01:00 pm and observed a supply of seven-day non-perishable and frozen foods. Two day perishable foods will be purchased when there are clients present. Frozen foods are properly wrapped and stored. Food storage and preparation areas are clean and inaccessible to pests. Knives are stored in the cabinet above the kitchen stove and were double locked and inaccessible to clients.

Bathrooms: At 01:10 pm LPA observed all bathrooms to have non-skid matts and the appropriated wash your hands signs posted in the bathroom. Hot water was tested and measured within regulation at 110 degrees F.

Resident Rooms: At 01:25 pm, LPA observed rooms to have the appropriate bedding. There is a nightstand, a chair and sufficient lighting for each resident.

Laundry: At 01:35 pm, LPA observed a locked laundry room with locked cabinets for chemicals/toxins. LPA observed detergents and cleaning supplies in the locked cabinet. LPA observed extra linens in a cabinet located inside a restroom hallway. LPA observed an emergency food supply closet in the hallway.

Garage At 01:45 pm LPA observed the attached garage, used for extra storage.

Physical environment: LPA toured the outside area of the facility at 02:00 pm. LPA observed appropriate outdoor furniture. LPA observed 2 umbrellas used for shade stored in the garage due to high winds. There are no bodies of water on the premises.

Administrative: Annual fee is current. Bond and Administrator Certificate will be emailed to LPA.

Resident/Staff Files: There are no clients or staff as of yet. No files were reviewed.



Medications: There are no medications as there are no clients.

There are no deficiencies to report and no citations to be issued. Exit interview conducted and a copy of the report was emailed to the Administrator.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024
LIC809 (FAS) - (06/04)
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