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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002908
Report Date: 05/08/2023
Date Signed: 05/08/2023 02:01:00 PM


Document Has Been Signed on 05/08/2023 02:01 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



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: 6DATE:
05/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Hossai MomenTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Melissa Parks arrived on Monday May 8, 2023 to conduct the annual inspection.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA Parks reviewed resident (6) and staff files (2). All resident files contained the required paperwork. All staff files contained the required paperwork and training. All staff have current first aid and CPR training. First aid kit was fully stocked. Facility had a full supply of PPE including face shields, surgical masks, N95s, and gowns. Facility was clean and well organized. All required posting were observed.

LPA Parks and Hossai toured the facility together to ensure the health and safety of residents in care. The areas toured included resident rooms, bathrooms, kitchen, common areas, and backyard. In the areas toured, there were no health or safety violations observed.

No deficiencies cited. Exit interview conducted. A copy of this report was emailed to the Administrator. .
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:
DATE: 05/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2023
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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