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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700033
Report Date: 02/27/2023
Date Signed: 02/27/2023 10:47:35 AM


Document Has Been Signed on 02/27/2023 10:47 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
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:GRANITE BAY COUNTRYHOUSE LLCFACILITY NUMBER:
312700033
ADMINISTRATOR:JESSICA SANDERSFACILITY TYPE:
740
ADDRESS:8485 BARTON RDTELEPHONE:
(916) 899-6565
CITY:GRANITE BAYSTATE: CAZIP CODE:
95746
CAPACITY:49CENSUS: 35DATE:
02/27/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jessica SandersTIME COMPLETED:
10:45 AM
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LPA Parks arrived on Monday February 27, 2023 to conduct a case management visit. Prior to the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask.

This is a follow up visit for an incident that occurred on 2/24/2023. S1 heard a resident scream. S1 approached the hallway and observed R1 and R2. R1 complained of a scratch on their right forearm from R2. First aid was provided. Primary physicians and POAs for R1 and R2 were notified.

LPA discussed the incident with Administrator Jessica. LPA obtained copies of R1 and R2's physicians reports, care plans, and current medication lists. LPA is requesting copies of updated care plans by 2/28/2023.

No deficiencies are being cited. Exit interview conducted.

SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:
DATE: 02/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2023
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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