<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 297005250
Report Date: 07/31/2023
Date Signed: 07/31/2023 02:05:19 PM


Document Has Been Signed on 07/31/2023 02:05 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:NATASHA GEORGESFACILITY TYPE:
740
ADDRESS:150 SUTTON WAYTELEPHONE:
(530) 272-1055
CITY:GRASS VALLEYSTATE: CAZIP CODE:
95945
CAPACITY:116CENSUS: 77DATE:
07/31/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Natasha GeorgesTIME COMPLETED:
02:30 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
Licensing Program Analyst (LPA) Melissa Parks arrived on Monday July 31, 2023 to conduct the unannounced annual inspection.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed resident (8) and staff (8) files. All resident files contained the required paperwork. All staff files contained the required paperwork and training. Facility is complaint with fire drills. Additionally, LPA reviewed elopement drills.

LPA, Executive Director, and Resident Services 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, memory care courtyard, assisted living apartments, assisted living courtyard, lobby, kitchen, and laundry rooms. LPA observed the facility's emergency food, water storage and PPE. All water temperatures were within the required range. In the areas toured, there were no health or safety violations observed.

LPA obtained a copy of the facility's current liability insurance and LIC500. Administrator will email LPA an updated copy of LIC610E by 8/4/2023.

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: 07/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2023
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 1