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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700862
Report Date: 09/27/2023
Date Signed: 09/27/2023 04:53:09 PM


Document Has Been Signed on 09/27/2023 04:53 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 SPRING CARE HOME 4FACILITY NUMBER:
312700862
ADMINISTRATOR:NESTERUK, TATYANAFACILITY TYPE:
740
ADDRESS:6206 GOLDENEYE CT.TELEPHONE:
(916) 879-4405
CITY:ROCKLINSTATE: CAZIP CODE:
95765
CAPACITY:6CENSUS: 3DATE:
09/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Tatyana NesterukTIME COMPLETED:
05:00 PM
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LPA Hiratsuka, conducted this unannounced annual visit. LPA toured the facility with Caregiver. Administrator showed up a short time later and completed visit with LPA.

This facility has a fire clearance for six non-ambulatory residents. This facility has four resident rooms. Three of the rooms may be shared and one is private. However, if the three rooms are going to be shared, then the private room shall not be used for residents. To the left of the main entrance is a doorway leading to a hallway that leads to the bedrooms. There is a common half bathroom, a common full bathroom, and laundry room, and the four bedrooms. The largest of the resident rooms has a full private bathroom and an exit to the outside. To the right and front of the main entrance is the kitchen, dining, and main common areas. There is also a door leading to the garage from the kitchen. The backyard was inspected. There is a covered patio area and the backyard is well maintained. There is a gate on the same side as the garage. There are locked cabinets for sharp knives and medications. The cabinets in the laundry room are locked.

Multiple topics were discussed.

The following shall be updated and submitted to Community Care Licensing by 10/15/2023:
-LIC 500 facility personnel or staff schedule
-LIC 610 emergency disaster plan
-LIC 308 designation of administrative responsibility

No deficiencies cited.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2023
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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