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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002984
Report Date: 12/01/2022
Date Signed: 12/01/2022 10:49:22 AM

Document Has Been Signed on 12/01/2022 10:49 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
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:GRANITE MEADOW HOMEFACILITY NUMBER:
315002984
ADMINISTRATOR:SORONGON, ESPERANZAFACILITY TYPE:
734
ADDRESS:3115 GRANITE MEADOWS LNTELEPHONE:
(650) 580-3896
CITY:GRANITE BAYSTATE: CAZIP CODE:
95746
CAPACITY: 5CENSUS: 4DATE:
12/01/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Espie SorongonTIME COMPLETED:
11:00 AM
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LPA Parks arrived on Thursday December 1, 2022 to conduct a case management visit. Prior to the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask.

LPA and Administrator reviewed changes with resident binders including currently monthly orders organized by routine medication orders, PRN medications, external orders, and treatment orders/ancillary orders. Facility also created the following documents: monthly consultant log, daily nursing report, and in-service training related to new care plans.

LPA obtained copies of the following documents: consultant log, integrated progress notes, seizure record, nurses notes/flowsheet, and RN head to toe assessment.

LPA toured the facility with Administrator Espie.


No deficiencies cited. Exit interview conducted.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Melissa Parks
LICENSING EVALUATOR SIGNATURE: DATE: 12/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/01/2022
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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