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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 297005250
Report Date: 08/27/2024
Date Signed: 08/27/2024 02:41:55 PM


Document Has Been Signed on 08/27/2024 02:41 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:ATRIA GRASS VALLEYFACILITY NUMBER:
297005250
ADMINISTRATOR:PHOEBIE CARCOTFACILITY TYPE:
740
ADDRESS:150 SUTTON WAYTELEPHONE:
(530) 272-1055
CITY:GRASS VALLEYSTATE: CAZIP CODE:
95945
CAPACITY:116CENSUS: 96DATE:
08/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Phoebie CarcotTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Melissa Parks arrived on Tuesday August 27, 2024 to conduct the unannounced annual inspection.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed resident (9) and staff (6) files. All resident files contained the required paperwork. All staff files contained the required paperwork and training. Facility was compliant with fire drills and an annual evacuation drill.

LPA, Administrator, and Life Guidance Director toured the facility together to ensure the health and safety of residents in care. The areas toured included memory care apartments, memory care common areas, assisted living apartments, lobby, kitchen, and dining room. LPA observed the facility's emergency food, water storage and PPE. LPA observed all required postings. LPA observed emergency evacuation chairs in each stairwell. First aid kit was fully stocked. Fire Extinguishers had current inspection tags. Carbon monoxide detectors were observed in each hallway. In the areas toured, there were no health or safety violations observed.

LPA obtained a copy of the facility's current liability insurance, LIC500, and LIC610E.

No deficiencies cited. Exit interview conducted. A copy of this report was emailed to the Administrator.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:
DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2024
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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