<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425802114
Report Date: 11/23/2021
Date Signed: 11/24/2021 08:07:38 AM

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 CAREFACILITY NUMBER:
425802114
ADMINISTRATOR:KAWANA ANTHONYFACILITY TYPE:
740
ADDRESS:5464 CARPINTERIA AVETELEPHONE:
(805) 566-0017
CITY:CARPINTERIASTATE: CAZIP CODE:
93013
CAPACITY:83CENSUS: 53DATE:
11/23/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:22 AM
MET WITH:Kawana Anthony, AdministratorTIME COMPLETED:
03:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced Case Management visit at the facility. LPA met with Administrator Kawana Anthony and announced the purpose of the visit.

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

During today's visit, LPA conducted interviews and obtained copies of documents pertinent to the visit from 11:30 am – 2:15 pm,

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 BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 11/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1