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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700862
Report Date: 11/07/2024
Date Signed: 11/07/2024 03:20:37 PM

Document Has Been Signed on 11/07/2024 03:20 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/
DIRECTOR:
NESTERUK, TATYANAFACILITY TYPE:
740
ADDRESS:6206 GOLDENEYE CT.TELEPHONE:
(916) 879-4405
CITY:ROCKLINSTATE: CAZIP CODE:
95765
CAPACITY: 6CENSUS: 4DATE:
11/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:35 PM
MET WITH:Tatyana NesterukTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Licensing Program Analysts (LPAs) Cassandra Mikkelson and Michael Hood arrived unannounced to conduct an annual inspection. LPAs met with Tatyana Neteruk during today's inspection.

LPAs conducted an inspection of the care home to ensure compliance with Title 22 regulations. LPAs observed four (4) resident rooms and two (2) common area bathrooms. LPAs observed rooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition, properly maintained, and the hot water temperature was observed to be 120 degrees F.

LPAs checked the kitchen area for the ability to prepare and store food. Care home has required (2) two day perishable and (7) seven day non-perishable food supply on hand. Smoke detectors and carbon monoxide detectors are operational in the care home. Fire extinguishers and first aid kit are maintained and ready for emergency use. LPAs checked medication storage and found medications to be locked away and inaccessible to the residents. LPAs reviewed four (4) resident files and three (3) staff files and two (2) resident medications. Facility has a current copy of certificate of liability insurance and LPAs obtained a copy.

As a result of this visit, no deficiencies were cited.

Exit interview was conducted with Administrator. A copy of this report provided.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassandra Mikkelson
LICENSING EVALUATOR SIGNATURE: DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2024
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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