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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425802114
Report Date: 02/23/2022
Date Signed: 02/23/2022 02:36:39 PM


Document Has Been Signed on 02/23/2022 02:36 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, 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: 51DATE:
02/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Kawana AnthonyTIME COMPLETED:
02:50 PM
NARRATIVE
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On 02/23/22 at 11:45 a.m., Licensing Program Analyst (LPA) Toan Luong conducted an unannounced One Year Infection Control Annual visit to the facility. LPA met with Administrator Kawana Anthony and explained the purpose of the visit.

LPA was screened at the entrance, and LPA toured of the the residential care facility for the elderly. At 12:50 p.m., LPA discussed items in the Infection Control Module and noted that facility has not completed fit testing N95 with facility staff. All other items in the Infection Control Module were answered yes. Infection Control module was addressed with administrator to satisfaction. Between 1:25 p.m. and 2:00 p.m., LPA reviewed LIC 500 Personnel Roster and found 1 individual working at the facility without a completed Criminal Record Clearance transfer request. LPA received a copy of LIC 508, LIC 9182, and a copy of driver's license for staff affected from the administrator. LPA associated the staff to the facility via transfer request as staff was currently cleared at another Community Care Licensing facility. LPA issued citation under Title 22, Division 6 Chapter 8 Article 06. Background Check 87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c).

Deficiency issued on LIC 809D. A civil penalty was issued. LPA conducted exit interview with administrator and emailed a copy of today's report and appeal rights to the administrator.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Toan LuongTELEPHONE: (626) 419-1827
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2022
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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Document Has Been Signed on 02/23/2022 02:36 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type A
Section Cited
CCR
87355(e)(2)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, one staff was not associated to the roster. The licensee did not comply with the section cited above in 1 count which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/24/2022
Plan of Correction
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LPA received LIC 9182, LIC 508, and copy of current driver's license. LPA completed transfer request from other facility. Administrator will verify roster before allowing employee to work.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Toan LuongTELEPHONE: (626) 419-1827
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2022
LIC809 (FAS) - (06/04)
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