475002785-7-19-2024-59-AS-SBEN-D7BVHU-20240719162743

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 475002785
Report Date: 07/19/2024
Date Signed: 07/19/2024 04:27:52 PM

Document Has Been Signed on 07/19/2024 04:27 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
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: 22	DATE:	07/19/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Alma Peralta Administrator		TIME COMPLETED:	04:30 PM

NARRATIVE

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07/19/2024 11:45 AM Licensing Program Analyst (LPA) Sarah Benson arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with administrator Alma Peralta (cert #6068027740 exp.5-31-25) and explained the purpose of the visit. Administrator certificate is current.

LPA Benson and administrator toured the facility together to ensure the health and safety of residents in care. Areas toured include but are not limited to four (4) resident rooms, common areas, two (2) bathrooms, storage areas, dinning areas and back yard. Staff and resident files were reviewed. Medications were also reviewed. Medication is locked in a locked closet.

The common area was clean and in good repair. All bedrooms had required furniture, bedding, and lighting. The bathrooms were clean and in good repair. The dinning area was clean and in good repair.

The facility was observed to be at a comfortable temperature. First aid kit fully stocked and ready for emergency use. Fire extinguisher fully charged. Smoke detectors are all operational. Hot water temperature did not measure within required Title 22 regulations of 105 degrees F and 120 degrees F. All employees requiring background checks are cleared. There is a schedule of activities planned for the clients. All required postings are displayed within the facility.

No pools/bodies of water are on the premises. No firearms are on premises. The last disaster drill was conducted and documented on 7-2-24, the facility has been conducting drills every 3 months.

The following deficiencies were observed (See LIC 809D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted and copy of report and appeal rights was provided to administrator.

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Sarah Benson	TELEPHONE: 530-895-5033
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024

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 07/19/2024 04:27 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GRENADA GARDENS SENIOR LIVING, LLC	FACILITY NUMBER: 475002785
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and intervie, the licensee did not comply with the section cited above in two out of twenty nine rooms water temp. were tested at 77.4 and 73 degrees, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/26/2024
	Plan of Correction
1 2 3 4	Pay the propane bill. Prof of payment sent to LPA. Prof the water temp. is between 105 and 120 in rooms 101 & 126 sent to LPA Benson.

Type B

Section Cited

HSC

1569.618(c)(4)

Other Provisions

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (4) Ensure that the facility is clean, safe, sanitary, and in good repair at all times. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in that the rooms and hall by 108 smells like urine, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/02/2024
	Plan of Correction
1 2 3 4	Clean the carpet every other day. Look at replacing the flooring. More frequently room/resident check. Notify LPA when complete

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: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Sarah Benson	TELEPHONE: 530-895-5033
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024

LIC809 (FAS) - (06/04)

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