312700033-5-5-2022-25-AS-KHIA-CE5QAZ-20220505120046

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 312700033
Report Date: 05/05/2022
Date Signed: 05/05/2022 12:00:51 PM

Document Has Been Signed on 05/05/2022 12:00 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME:	GRANITE BAY COUNTRYHOUSE LLC		FACILITY NUMBER:	312700033
ADMINISTRATOR:	JESSICA SANDERS		FACILITY TYPE:	740
ADDRESS:	8485 BARTON RD		TELEPHONE:	(916) 899-6565
CITY:	GRANITE BAY	STATE: CA	ZIP CODE:	95746
CAPACITY:	49	CENSUS: 21	DATE:	05/05/2022
TYPE OF VISIT:	Case Management - Health Checks	UNANNOUNCED	TIME BEGAN:	09:42 AM
MET WITH:	Jessica Sanders		TIME COMPLETED:	12:10 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) Kerry Hiratsuka arrived at the facility unannounced on 05/05/2022, to conduct a Case Management Visit. LPA conducted COVID-19 Precautionary prescreening, and wore a surgical mask while at facility. LPA were screened by Front Desk. LPA conducted this visit in response to Executive Director (ED) reporting the facility is on fire watch. Yesterday during routine maintenance on the facility fire control system the fire control panel stopped working. Because the fire panel is connected to the elevator, the elevators cannot work until the control panel is repaired. Residents are escorted by staff when walking up and down the stairs. ED stated she was given an estimate time of repair is a week and stated if it is not repaired by noon on 05/11/2022, all residents who reside upstairs shall be moved downstairs until the panel is repaired. LPA toured the facility and observed all residents participating in activities. No hazards were observed. Today the following was obtained: -obtained the fire watch protocol. -obtained the fire watch company information -phone number of the fire department the facility called to report what occurred -resident staff roster -staff schedule The following shall be done by the facility until this event is over: -implement fire watch -conduct 24 hour fire watch consisting of continuous patrol of all areas of the building to look for evidence of smoke, fire, or any abnormal conditions -respond to any life-threatening situations by immediately contacting emergency personnel, alert residents to the emergency and assist in their evacuation -submit fire watch log by 5:00pm everyday until the panel is repaired and cleared by the fire department

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry Hiratsuka	TELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 LLC	FACILITY NUMBER: 312700033
	VISIT DATE: 05/05/2022

NARRATIVE

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-Facility shall ensure the fire watcher has full access and readily available to any and all fire protection equipment should they discover a fire.
-All activities associated to the fire watch shall be documented. Therefore anyone conducting fire watches shall be trained on how to do them and how to complete the fire watch log

Facility shall develop and maintain a current fire watch policy that specifies the following:
-The duties the employees are to perform when conducting the fire watch and the equipment they must be provided and the purpose of the equipment
-Personal Protective Equipment (PPE) shall be made available and they shall wear them during the fire watch
-The fire watch shall remain in effect until the entire system is restored to proper working order and only after any necessary inspections and tests have been conducted to verify the affected systems are operational and the fire department is notified.

Facility shall send the Community Care Licensing Division (CCLD) Regional Office a formal written plan on the fire watch and plan to order and restore the affected fire panels.

Facility shall send a copy to CCLD a copy of any and all fire reports and the names and contacts of the fire department.

No deficiencies cited.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry Hiratsuka	TELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2022

LIC809 (FAS) - (06/04)

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