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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002907
Report Date: 06/28/2023
Date Signed: 06/28/2023 12:49:10 PM


Document Has Been Signed on 06/28/2023 12:49 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 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: 3DATE:
06/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Shahbaz KhanTIME COMPLETED:
12:30 PM
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LPA Parks arrived on Wednesday June 28, 2023 to complete the unannounced annual inspection.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA Parks reviewed resident (3) and staff files (2). All resident files contained the required paperwork. Staff files contained the required paperwork and training (initial and annual).

LPA Parks and Administer Shahbaz toured the facility together to ensure the health and safety of residents in care. The areas toured included resident rooms, bathrooms, kitchen, and outdoor area. Water temperatures in kitchen and bathrooms were within the required range of temperatures. Facility has a fire extinguisher with a current inspection. First aid kit is fully stocked. Facility meets the perishable and nonperishable food requirements. In the areas toured, there were no health or safety violations observed.


Exit interview conducted. A copy of this report was emailed to Facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2023
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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