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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601153
Report Date: 08/12/2022
Date Signed: 08/12/2022 12:55:02 PM

Document Has Been Signed on 08/12/2022 12:55 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:GRANADA HILLSFACILITY NUMBER:
374601153
ADMINISTRATOR:KATHY NELSONFACILITY TYPE:
735
ADDRESS:3990 N. GRANADA AVENUETELEPHONE:
(619) 660-0416
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91977
CAPACITY: 6CENSUS: 5DATE:
08/12/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:17 AM
MET WITH:Kathy Nelson, AdministratorTIME COMPLETED:
10:49 AM
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Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced Case Management visit. LPA was identified herself and with Kathy Nelson. We discussed the purpose of the visit.

Today’s visit was in response to the death of Client #1 which licensee self-reported. It was reported C1 passed away on August 10, 2022 at the hospital.

LPA briefly toured the facility, performed a welfare check on clients in care, interviewed staff, and obtained copies of pertinent facility records. No deficiencies were observed or cited on this date.

An exit interview was conducted with Nelson, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided at the end of the visit.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 08/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/12/2022
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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