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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
475002785
Report Date:
11/02/2023
Date Signed:
11/03/2023 08:26:55 AM
Document Has Been Signed on
11/03/2023 08:26 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
SACRAMENTO NORTH ASC
,
9835 GOETHE ROAD, SUITE 100
SACRAMENTO
,
CA
95827
FACILITY NAME:
GRENADA GARDENS SENIOR LIVING, LLC
FACILITY NUMBER:
475002785
ADMINISTRATOR:
BURSTEIN, NAFTALI
FACILITY TYPE:
740
ADDRESS:
424 HIGHWAY A-12
TELEPHONE:
(530) 436-2514
CITY:
GRENADA
STATE:
CA
ZIP CODE:
96038
CAPACITY:
90
CENSUS:
20
DATE:
11/02/2023
TYPE OF VISIT:
Case Management - Deficiencies
UNANNOUNCED
TIME BEGAN:
02:00 PM
MET WITH:
Jace Freitas Marketing Specialist
TIME COMPLETED:
02:45 PM
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On 11-02-23 Licensing Program Analyst LPA Sarah Benson met with Jace Freitas Marketing Specialist to clear 809-D dated 06-21-23. Administrator was not on site and not all files were available.
LPA Sarah Benson and Jace Freitas toured the facility to verify the health and safety of residents in care.
LPA was not able to clear 809-D at this time.
SUPERVISOR'S NAME:
Lauren Crocker
TELEPHONE:
(916) 261-4966
LICENSING EVALUATOR NAME:
Sarah Benson
TELEPHONE:
530-895-5033
LICENSING EVALUATOR SIGNATURE:
DATE:
11/02/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/02/2023
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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