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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002908
Report Date: 07/20/2022
Date Signed: 07/20/2022 03:27:53 PM


Document Has Been Signed on 07/20/2022 03:27 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 IFACILITY NUMBER:
315002908
ADMINISTRATOR:KHAN, SHAHBAZFACILITY TYPE:
740
ADDRESS:8342 JOE RODGERS ROADTELEPHONE:
(916) 300-6967
CITY:GRANITE BAYSTATE: CAZIP CODE:
95746
CAPACITY:6CENSUS: 5DATE:
07/20/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Shahbaz KhanTIME COMPLETED:
02:00 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 I Facility #312700537. Applicant holds a current administrator certificate (# 6062273740 with expiration date 01/27/2024). The facility currently has 5 residents . There is one resident on hospice. No residents are on oxygen. This is a change of ownership. There is fire clearance for 6 non-ambulatory residents in this facility and facility has a waiver for 3 hospice residents at this time.

LPA toured the facility with Shahbaz. The food supply is within compliance, 2 days of perishable and 7 days’ worth of non-perishable food items. Smoke detectors are operational. There are (2) carbon monoxide detectors which are functioning. The Fire extinguisher was charged, serviced and functional. Grab bars were present at the toilet and in the shower. All exits were unobstructed. All toxins, medications, and sharps were locked and stored away. The disaster drill is current. The administrator's certificate is current. There is a side gate for emergency access.

During the walk-through LPA was not able to look inside resident bedrooms due to active COVID-19 cases. Component III was waived as the current administrator has done Component III for another facility during today's inspection. 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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