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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002907
Report Date: 06/20/2025
Date Signed: 06/20/2025 02:21:20 PM

Document Has Been Signed on 06/20/2025 02:21 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/
DIRECTOR:		CRUZ, MARY ROSEFACILITY TYPE:
740
ADDRESS:8352 JOE RODGERS ROADTELEPHONE:
(916) 872-1444
CITY:GRANITE BAYSTATE: CAZIP CODE:
95746
CAPACITY: 6CENSUS: 6DATE:
06/20/2025
TYPE OF VISIT:OfficeUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Shahbaz KhanTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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On June 20, 2025, the Department representatives, LPA Kevin Mknelly and Licensing Program Manager, Troy Ordonez held a virtual office meeting via Microsoft Teams with licensee member, Shahbaz Khan, the proposed change of ownership applicant and the applicant’s business agent to discuss the proposed change of ownership for the licensed facilities Granite Bay Villas I- 315002908 and Granite Bay Villas II 315002907 . During the meeting, the Department outlined Title 22 requirements and clarified the following:

A formal Change of Ownership (CHOW) application must be submitted and approved by the Department before any transfer of operational control can occur. No party may assume control or operate the facility without a valid license issued by the Department.

If a management company is intended to oversee daily operations (including liability insurance, workers’ compensation, and payroll), the current licensee must submit a revised LIC 200 to add the management company to the existing license. The licensee may delegate responsibilities but remains legally accountable unless and until licensure is transferred.

NAME OF LICENSING PROGRAM MANAGER: Maribeth Senty
NAME OF LICENSING PROGRAM ANALYST: Kevin Mknelly
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
VISIT DATE: 06/20/2025
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The Department emphasized that the current licensee remains the legally responsible party for the facility until the proposed applicant is officially licensed.

Due to the change of ownership, the department requires the following documents to be submitted to LPA Mknelly: a revised lease agreement with the correct landlord/owner of the property and a new LIC200/ application if a formal management company is to be added to the existing license. Documents to be submitted by 6/27/25.

Letters of intent to close to all residents and their responsible parties, the local Long-Term Care Ombudsman. Additionally, as a change of ownership, and the resulting termination of an admission agreement, residents shall receive agreement termination notices that contain required information in CCR 87224- Eviction Procedures. Both the intent to close and eviction notice are to be submitted to CCLD.

As a result of today’s meeting, no deficiencies are found. LPA Mknelly provided a copy to Shahbaz Khan for review, signature and return by email.

NAME OF LICENSING PROGRAM MANAGER: Maribeth Senty
NAME OF LICENSING PROGRAM ANALYST: Kevin Mknelly
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2025
LIC809 (FAS) - (06/04)
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