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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 475002785
Report Date: 06/15/2022
Date Signed: 06/15/2022 04:04:06 PM


Document Has Been Signed on 06/15/2022 04:04 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:GRENADA GARDENS SENIOR LIVING, LLCFACILITY NUMBER:
475002785
ADMINISTRATOR:BURSTEIN, NAFTALIFACILITY TYPE:
740
ADDRESS:424 HIGHWAY A-12TELEPHONE:
(530) 436-2514
CITY:GRENADASTATE: CAZIP CODE:
96038
CAPACITY:90CENSUS: DATE:
06/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Administrator Mike BusteinTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Misty Valencia, arrived at the facility unannounced on 06/15/2021 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Administrator Mike Bustein, and explained the purpose of the visit. Prior to initiating the annual inspection visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted Facility Med Tech and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPA was screened by the concierge.

LPA and Administrator toured facility together to ensure health and safety of the facility. Areas toured include but are not limited to: common areas, resident bedrooms, and common restroom. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Administrator completed the infection control domain and facility was found to be in substantial compliance at this time.


No deficiencies are being cited as a result of todays inspection.

Exit interview conducted and copy of report left at the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Misty ValenciaTELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:
DATE: 06/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2022
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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