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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347000958
Report Date: 04/14/2022
Date Signed: 04/14/2022 11:34:43 AM


Document Has Been Signed on 04/14/2022 11:34 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:GRANNY'S COTTAGEFACILITY NUMBER:
347000958
ADMINISTRATOR:ADALBERTH BANCUFACILITY TYPE:
740
ADDRESS:7717 DEANTON COURTTELEPHONE:
(916) 729-9319
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:6CENSUS: 5DATE:
04/14/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Albert Bancu, AdministratorTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct a case management visit. LPA met with administrator Albert Bancu during today's inspection. 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 they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical masks.

LPA received a death report from administrator and arrived to review documentation. LPA reviewed R1's facility file and observed R1's LIC602 indicates resident was receiving hospice care. Resident was on hospice services when R1 passed.

No deficiencies cited during today's inspection.

Exit interview conducted.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2022
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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