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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700033
Report Date: 09/12/2024
Date Signed: 09/12/2024 03:17:04 PM


Document Has Been Signed on 09/12/2024 03:17 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:JAMES HALLFACILITY TYPE:
740
ADDRESS:8485 BARTON RDTELEPHONE:
(916) 899-6565
CITY:GRANITE BAYSTATE: CAZIP CODE:
95746
CAPACITY:49CENSUS: 29DATE:
09/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:James HallTIME COMPLETED:
03:15 PM
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Licensing Program Analysts (LPAs) Melissa Parks and Cassandra Mikkelson arrived on Thursday September 12, 2024 to conduct the unannounced annual inspection.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPAs reviewed resident (6) and staff (6) files. All resident files contained the required paperwork. All staff files contained the required paperwork and training.

LPAs and Administrator toured the facility together to ensure the health and safety of residents in care. The areas toured included apartments, common areas, kitchen, and dining room. LPAs observed all required postings. LPA observed emergency evacuation chairs in each stairwell. First aid kit was fully stocked. Fire Extinguishers had current inspection tags. Facility was clean and well organized. Residents were engaged in activities during LPAs visit. Water temperatures were within the required range. In the areas toured, there were no health or safety violations observed.

LPAs requested the following: a copy of the facility's current liability insurance, updated LIC500 and LIC610E by the end of the month.

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: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2024
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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