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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002064
Report Date: 03/15/2022
Date Signed: 03/15/2022 02:56:38 PM

Document Has Been Signed on 03/15/2022 02:56 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: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:
03/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrator Daniel CosteaTIME COMPLETED:
03:10 PM
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Licensing Program Analysts (LPA) B. Mirlohi and L. Muscan arrived at the facility unannounced to conduct an annual visit using the infection control tool visit. LPAs met with Administrator Daniel Costea 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. 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. Facility has a 2 day perishable and a 7 day non-perishable amount of food. Facility has 6 residents 1 of which is on hospice. LPAs and Administrator completed the infection control domain and facility was found to be in substantial compliance at this time.


Administrator provided an updated LIC500 and liability insurance.

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

Exit interview conducted and copy of report left at the facility.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE: DATE: 03/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/15/2022
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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