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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002921
Report Date: 09/21/2022
Date Signed: 09/21/2022 05:45:41 PM


Document Has Been Signed on 09/21/2022 05:45 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:GRANNY'S COTTAGE LLCFACILITY NUMBER:
345002921
ADMINISTRATOR:BANCU, ADALBERTHFACILITY TYPE:
740
ADDRESS:7717 DEANTON CT.TELEPHONE:
(916) 606-9670
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:6CENSUS: 3DATE:
09/21/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Adalberth "Albert" Bancu, Administrator TIME COMPLETED:
05:45 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a pre-licensing inspection for a change in ownership. LPA met with Albert Bancu, Administrator and explained purpose of inspection. LPA observed (3) residents to be resting in their rooms. The facility is currently licensed for (6) non-ambulatory residents and has a hospice waiver for (6). Currently, there are (2) residents on hospice. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols and completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the facility, and wore the following Personal Protective Equipment (PPE): N95 mask. LPA was advised that (1) positive resident case was reported to the department earlier today and reviewed LIC624 that was faxed over.

LPA and Administrator toured the interior and exterior of the facility including the common areas, resident bedrooms (4), resident bathrooms (2), kitchen, staff room and laundry/garage. LPA observed the facility to be clean, in good repair and to have sufficient furniture and lighting. LPA observed the bathrooms to have the necessary grab bars, non-skid flooring, paper towels, trash cans with lids and hand-washing posters. LPA observed sufficient 2+day perishable and 7+day non-perishable supply of food, locked sharps and medications in the kitchen and locked toxins in the laundry/garage area. LPA observed the inside temperature to be 78*F. Fire extinguisher was last serviced on 6/14/2022. Alarms on all exit doors and LPA observed (1) exterior gate to be unlocked from the inside and an inoperable fountain to be gated outside. Discussed vaccination status of residents/staff, eligibility for boosters and visitation protocols. PPE supply is sufficient. LPA observed required postings posted throughout. LPA discussed how the current Licensee notified residents/representatives about ownership change and paperwork to be completed upon ownership change. Administrator certificate #6019037740 is pending renewal by the department. LPA observed organized resident/staff files and staff to have current training documentation. Component III was reviewed during today’s inspection. It appears the facility is in substantial compliance and there are no deficiencies being noted today.

Exit interview done. Copy of report provided to Administrator.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2022
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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