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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700033
Report Date: 09/24/2021
Date Signed: 09/24/2021 04:06:45 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:GRANITE BAY COUNTRYHOUSE LLCFACILITY NUMBER:
312700033
ADMINISTRATOR:ANDREA C ARMSTRONGFACILITY TYPE:
740
ADDRESS:8485 BARTON RDTELEPHONE:
(916) 899-6565
CITY:GRANITE BAYSTATE: CAZIP CODE:
95746
CAPACITY:49CENSUS: 26DATE:
09/24/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Andrea ArmstrongTIME COMPLETED:
01:00 PM
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LPA Tryon arrived at the facility on 9/24/21 to perform an annual visit using the Infection Control Domain. Prior to the visit, LPA had checked with the facility to ensure they do not have any COVID Positive Residents or staff. LPA did a self-screening by taking temperature and reviewing possible symptoms. LPA wore a surgical mask and used hand sanitizer. LPA met with Administrator Andrea Armstrong.

LPA toured the facility including common areas, dining rooms, resident rooms, bathrooms, hallways, patio, yard.

LPA reviewed the infection control domain with the Administrator. LPA requested a copy of most recent Administrator Certificate, copy of liability insurance, and current staff schedule.

The facility appears to be in substantial compliance at this time.

Exit interview conducted
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 208-7709
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2021
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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