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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700033
Report Date: 08/24/2023
Date Signed: 08/24/2023 03:56:29 PM


Document Has Been Signed on 08/24/2023 03:56 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: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: 36DATE:
08/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Jessica SandersTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Melissa Parks and Licensing Program Analyst (LPA) Jaynae Boyles arrived on Thursday August 24, 2023 to conduct the unannounced annual inspection.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPAs reviewed resident (5) and staff (6) 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.

LPAs and Maintenance 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, and kitchen. LPAs observed the facility's emergency food, water storage and PPE. LPAs observed the water temperature in apartments #7, #18, and whirlpool room to be between 125 and 128 degrees which is a higher temperature than the regulation allows. See 809-D for citation.

LPAs obtained an updated copy of LIC610E and LIC500. Facility to email LPA with a copy of current liability insurance by the end of the month.

Exit interview conducted. Appeal rights were given. 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: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2023
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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Document Has Been Signed on 08/24/2023 03:56 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: GRANITE BAY COUNTRYHOUSE LLC
FACILITY NUMBER: 312700033

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 3 out of 6 water temperatures measuring above 120 degrees which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/25/2023
Plan of Correction
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Licensee to submit a statement of understanding regarding water temperature by end of day 8/25/2023. Licensee to take apartment water tempatures twice a day for 7 days and submit to LPA by 9/5/2023.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2023
LIC809 (FAS) - (06/04)
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