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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002907
Report Date: 07/20/2022
Date Signed: 07/20/2022 02:50:34 PM


Document Has Been Signed on 07/20/2022 02:50 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:GRANITE BAY VILLAS IIFACILITY NUMBER:
315002907
ADMINISTRATOR:KHAN, SHAHBAZFACILITY TYPE:
740
ADDRESS:8352 JOE RODGERS ROADTELEPHONE:
(916) 300-6967
CITY:GRANITE BAYSTATE: CAZIP CODE:
95746
CAPACITY:6CENSUS: 0DATE:
07/20/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Shahbaz KhanTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPAs) Lavinia Muscan and Talwinder Bains met with applicant, Shahbaz Khan, to conduct an announced Pre- Licensing visit. LPAs followed current Covid precautions- self screened, hand sanitized and surgical mask worn. LPAs were screened upon arrival. This application is a change in ownership. This address is currently licensed as Granite Bay Villas II Facility #312700538. Applicant holds a current administrator certificate (# 6062273740 with expiration date 01/27/2024).

LPAs conducted an inspection of the care home to ensure compliance with Title 22 regulations. Facility inspection is done for these areas but not limited to six (6) bedrooms , two (2) bathrooms, storage area, outside area and laundry area . Bathrooms and bedrooms were in sanitary condition and properly maintained. LPAs checked the kitchen area for the ability to prepare and store food. Knives and Sharp objects found to be locked . LPAs observed cleaning products and other toxins to be locked away. LPAs observed the area used for medication to be locked and inaccessible to residents. LPAs observed smoke detectors and carbon monoxide detectors at the care home are operational. Fire extinguisher is ready for emergency use. Facility was approved for 6 non-ambulatory residents. Water temperature read at 111*.

Component III for RCFE was completed with Administrator during today's visit. LPAs will forward findings to the Centralized Application Bureau (CAB) that facility met all the pre-licensing components.

Applicant has satisfied all requirements in accordance to Title 22, California Code of Regulations on today's pre-licensing inspection. A copy of this report was provided to the facility. Exit interview conducted.

SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Lavinia MuscanTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2022
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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