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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317001256
Report Date: 02/28/2024
Date Signed: 02/29/2024 11:31:34 AM


Document Has Been Signed on 02/29/2024 11:31 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:CANA PLACEFACILITY NUMBER:
317001256
ADMINISTRATOR:SAMUEL LEEFACILITY TYPE:
740
ADDRESS:6965 BOARDWALK DRIVETELEPHONE:
(916) 797-6093
CITY:GRANITE BAYSTATE: CAZIP CODE:
95746
CAPACITY:6CENSUS: 6DATE:
02/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Samuel LeeTIME COMPLETED:
02:30 PM
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On 2/28/2024 LPA Tryon visited the facility to do an annual visit. LPA met with Administrator Samuel Lee
The facility currently has 6 residents.
LPA toured the house with Mr. Lee including common areas, kitchen, bedrooms, bathrooms, hallways, laundry, The home is very clean, in good condition, nicely furnished. Bedrooms have appropriate furnishings. Food supplies are adequate to meet the requirement of 2 days perishable and 7 days non-perishable food. Potentially hazardous items are secured. Medications are centrally stored and locked in a lower kitchen cabinet Smoke detectors/carbon monoxide detectors present and functioning, fire extinguisher present and charged.

LPA reviewed the CARE Tool with Administrator.
LPA reviewed 2 of 4 resident files; 3 staff files. LPA was not able to interview residents due to level of dementia.

At this time the facility appears to be in substantial compliance with the regulations. No deficiencies were noted.

LPA requested copies of most recent Administrator Certificate and Liability Insurance.

Exit interview conducted.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2024
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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