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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002907
Report Date: 07/24/2024
Date Signed: 07/25/2024 07:39:18 AM


Document Has Been Signed on 07/25/2024 07:39 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, 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: 5DATE:
07/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Shabaz KhanTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 7/24/24 to conduct a Annual Inspection utilizing the CARE inspection tool. LPA met with staff and explained the purpose of the visit. LPA requested for staff to notify Administrator that LPA is present at the facility to conduct an annual inspection. Administrator arrived to assist.

LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. The home is very clean and residents stated they are happy with care. Several issues discussed with licensee for non-citable issues. practices. Citations issued for a lapse in staffing and inoperable fire alarms. The staff who was shadowing was not supposed to do independent resident care but did so while scheduled staff stepped away. Both issues resolved while LPA was present.

LPA reviewed 5 resident files. Files are complete and well organized. Advisories discussed.

LPA reviewed 1 staff file. Files are complete.

Deficiencies are being cited as a result of todays inspection.


Exit interview conducted with licensee and copy of report and appeal rights left at the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 07/25/2024 07:39 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 II
FACILITY NUMBER: 315002907

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203

Fire Safety

All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observarions and stements, the licensee did not comply with the section cited above in the alarm was absent from R5's room and in the living room adjacent, since 7/23/24, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2024
Plan of Correction
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Licensee will replace the vacant alarms and confirm proper operation.
A photo of the correction will be emailed to LPA by 7/25/24
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 07/25/2024 07:39 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 II
FACILITY NUMBER: 315002907

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87413(a)(1)
Personnel - Operations
(1) When regular staff members are absent, there shall be coverage by personnel with qualifications adequate to perform the assigned tasks.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in S1 present and unsupervised which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2024
Plan of Correction
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Licensee to submit this weeks schedule and LIC 500 by the POC date of 7/31/24.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
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2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3