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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002064
Report Date: 12/17/2021
Date Signed: 12/17/2021 03:00:32 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:SENIOR CARE OF GRANITE BAYFACILITY NUMBER:
315002064
ADMINISTRATOR:COSTEA, DANIELFACILITY TYPE:
740
ADDRESS:9500 EDWARD COURTTELEPHONE:
(916) 768-4447
CITY:GRANITE BAYSTATE: CAZIP CODE:
95746
CAPACITY:6CENSUS: 6DATE:
12/17/2021
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Julie Thompson, CaregiverTIME COMPLETED:
03:10 PM
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Licensing Program Analysts (LPA) L. Muscan and K. Hiratsuka arrived at the facility unannounced on 12/17/2021 to conduct an unannounced annual visit using the infection control tool visit. LPAs met with Facility Caregiver Julie Thompson and explained the purpose of the visit. Prior to initiating the visit, LPAs completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted Facility Representative and completed a facility risk assessment. LPAs ensured they applied hand sanitizer prior to entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPAs were screened by Caregiver.

LPAs and Facility Caregiver toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, and common restrooms.. In the areas toured no immediate health, safety, or personal rights violations were observed. LPAs and Facility Caregiver completed the infection control domain and facility was found to be in substantial compliance at this time.

A couple of topics were discussed during today's visit.


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: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Lavinia MuscanTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021
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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