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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315001438
Report Date: 05/31/2023
Date Signed: 05/31/2023 11:00:06 AM


Document Has Been Signed on 05/31/2023 11:00 AM - 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



FACILITY NAME:GRANITE SPRING CARE HOME IIFACILITY NUMBER:
315001438
ADMINISTRATOR:FOKSHA, NATALYAFACILITY TYPE:
740
ADDRESS:208 AERIE COURTTELEPHONE:
(916) 782-9964
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:6CENSUS: 4DATE:
05/31/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator: Natalya Foksha TIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced on 05/31/2023 to conduct a Required-1 Year Inspection utilizing the CARE Inspection Tool. LPA met with Administrator, Natalya Foksha, and explained the purpose of the visit.

At 9:40 AM, LPA toured the interior and exterior of the facility to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, four (4) resident bedrooms, two (2) bathroom, kitchen, backyard, garage, and laundry room. LPA observed required furniture, and lighting throughout the residents' bedrooms and facility. LPA observed residents' bathrooms to be clean, sanitary, and in good repair. LPA observed food supplies of non-perishables for a minimum of one (1) week and perishable foods for a minimum of two (2) days. Toxic and cleaning supplies locked and is inaccessible to residents in care. The hot water temperature was measured in the kitchen at 105 degrees Fahrenheit. First aid kit was completed. LPA observed fire detectors, carbon monoxide alarms, and fire extinguisher to be operable. LPA observed medications to be locked and inaccessible to residents in care. LPA observed required Licensing posters posted throughout the facility.

At 10:00 AM, LPA reviewed a total of two (2) resident files. Resident files contain signed admission agreements, physician's reports, appraisals, identification sheets, releases, and resident's rights. Medications are centrally stored, locked, and appear to be given per doctor order. LPA compared medications to those being given for two (2) residents and found no discrepancies. Facility is correctly using the Medication Administration Records (MAR). LPA reviewed a total of one (1) staff record. Staff has training in first aid and CPR.

No deficiencies are being cited as a result of todays inspection.

Exit interview conducted and copy of report left at the facility.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2023
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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