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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002984
Report Date: 03/07/2023
Date Signed: 03/07/2023 03:39:56 PM

Document Has Been Signed on 03/07/2023 03:39 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 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:
03/07/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Espie SorongonTIME COMPLETED:
04:00 PM
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LPA Parks arrived on Tuesday March 7, 2023 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 was screened prior to entry. LPA, Administrator Espie, and Assistant Administrator Judee toured the facility together to ensure the health and safety of residents in care.

LPA, Administrator, and Assistant Administrator discussed the following forms which the facility has implemented: revised Daily Nursing Report and Monthly Change of Condition/Shift Charting Log. Upcoming admittance of a new resident was discussed.

Exit interview conducted. A copy of this report was left at the facility.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Melissa Parks
LICENSING EVALUATOR SIGNATURE: DATE: 03/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2023
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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