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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601153
Report Date: 05/25/2023
Date Signed: 05/25/2023 09:59:28 AM

Document Has Been Signed on 05/25/2023 09:59 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
SO. CAL AC/SC, 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:
05/25/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Annie Sonekeovilay and Benito BravoTIME COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA) Riza Alvarez conducted a case management visit. LPA was greeted and allowed entry into the facility by Annie Sonekeovilay, Caregiver. LPA stated the purpose of the visit was to follow up on a death of a client. Benito Bravo, Caregiver joined us after assisting a client.

During today's visit, three (3) of the clients are at Day Program. LPA briefly toured the facility, requested and obtained documents, and interviewed staff, including a telephone call with Administrator Kathy Nelson. On May 24, 2023, Community Care Licensing received a death report for Client #1 (C1). The report stated C1 passed away on May 23, 2023 at their bedroom. No deficiencies were observed or cited during this visit. LPA requested for a copy of the death certificate once available.

An exit interview was conducted and a copy of this report along with Licensee Rights (LIC9058 03/22) and LIC 811 (Confidential Names List) were provided to Annie Sonekeovilay whose signature below confirms receipt of these rights.
SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Riza Gloria Alvarez
LICENSING EVALUATOR SIGNATURE: DATE: 05/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2023
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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