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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315920153
Report Date: 09/05/2024
Date Signed: 09/05/2024 06:15:22 PM


Document Has Been Signed on 09/05/2024 06:15 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:JANNAT ASSISTED LIVINGFACILITY NUMBER:
315920153
ADMINISTRATOR:KUMARI ANJANAFACILITY TYPE:
740
ADDRESS:6882 BRANDY CIRCLETELEPHONE:
(408) 228-7611
CITY:GRANITE BAYSTATE: CAZIP CODE:
95746
CAPACITY:6CENSUS: 5DATE:
09/05/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Anjana KumariTIME COMPLETED:
06:15 PM
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Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 4/3/24 to conduct a Prelicensing Inspection utilizing the CARE tool. LPA Met with the licensee.

LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed.

LPA, reviewed a resident file . Files in process of corrections needed for prior licensee. Applicant will follow guidance for files in LIC 311F

Medication documentation procedure discussed. LPA referred Applicant to CCLD Medication guide on CCLD's website.

Component III was completed.

No deficiencies are being cited as a result of todays inspection. Facility is in significant compliance.

License is pending.

Exit interview conducted and copy of report left at the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2024
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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