425802114-10-18-2021-29-AS-KKOS-C7X2UT-20211018174251

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425802114
Report Date: 10/18/2021
Date Signed: 10/18/2021 05:43:14 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	GRANVIDA SENIOR LIVING AND MEMORY CARE		FACILITY NUMBER:	425802114
ADMINISTRATOR:	KAWANA ANTHONY		FACILITY TYPE:	740
ADDRESS:	5464 CARPINTERIA AVE		TELEPHONE:	(805) 566-0017
CITY:	CARPINTERIA	STATE: CA	ZIP CODE:	93013
CAPACITY:	83	CENSUS: 48	DATE:	10/18/2021
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Maribel Castro, Business Office Director		TIME COMPLETED:	05:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced Case Management visit at the facility. LPA met with Maribel Castro, Business Office Director and announced the purpose of the visit. Administrator Kawana Anthony was not available on this day.

On 10/13/2021, CCL received an eviction notice for Resident 1 (R1) due to non-payment of the rate for basic services.

LPA conducted a health and safety tour of the facility. From 2:10 pm to 4:30 pm, LPA conducted interviews and obtained copies of documents pertinent to the visit.

Due to time restraints, LPA will continue the investigation and return to the facility at a later date.

Exit interview conducted. Copy of report issued via email. No deficiencies were noted at this time.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2021

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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