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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850335
Report Date: 05/30/2023
Date Signed: 10/09/2023 12:24:38 PM


Document Has Been Signed on 10/09/2023 12:24 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
CENTRALIZED APP UNIT, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814



FACILITY NAME:GRANVIDA SENIOR LIVING AND MEMORY CAREFACILITY NUMBER:
425850335
ADMINISTRATOR:SPIRA, STEVEFACILITY TYPE:
740
ADDRESS:5464 CARPINTERIA AVENUETELEPHONE:
(805) 566-0017
CITY:CARPINTERIASTATE: CAZIP CODE:
93013
CAPACITY:83CENSUS: DATE:
05/30/2023
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Eric Terrill and Mike ShetlerTIME COMPLETED:
10:27 AM
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Component II completion: Successful

Facility Type: RCFE
Application Type:CHOW
Capacity:83
Census (if any clients in care):
COMP II Participants: Eric Terrill Administrator, Mike Shetler licensee
Interview Method:
Virtual interview (Teams)


On 5/30/23, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing readiness.
SUPERVISOR'S NAME: Tracy ThompsonTELEPHONE: (916) 651-7817
LICENSING EVALUATOR NAME: Amy AveryTELEPHONE: (916) 657-2592
LICENSING EVALUATOR SIGNATURE:
DATE: 05/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2023
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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