475002785-6-21-2023-59-AS-SBEN-CSZP77-20230621110326

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 475002785
Report Date: 06/20/2023
Date Signed: 06/21/2023 11:03:42 AM

Document Has Been Signed on 06/21/2023 11:03 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: 22	DATE:	06/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Mike Naftali Burstein		TIME COMPLETED:	02:30 PM

NARRATIVE

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06/20/2023 11:00 AM Licensing Program Analyst (LPA) Sarah Benson arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with Mike Burstein Administrator (cert #6003423740 exp.06-06-2023) and explained the purpose of the visit.

LPA Benson and the 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 (4) bathrooms, storage areas and back yard. In the areas toured no immediate health, safety, or personal rights violations were observed. Staff and resident files were reviewed. Medications were also reviewed.

Common area was clean and in good repair. All bedrooms had required furniture, bedding, and lighting. Bathrooms were clean and in good repair. Bistro, kitchen was clean and in good repair. Medication is locked in a locked closet.

Administrator certificate is current. First aid kit fully stocked and ready for emergency use. Fire extinguisher fully charged. Smoke detectors are all operational. Hot water temperature measured within required Title 22 regulations of 105 degrees F and 120 degrees F. All employees requiring background checks are cleared. All required postings are displayed within facility.

No pools/bodies of water are on premises. No firearms are on premises. Last disaster drill was conducted and documented on 04-02-23, 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 was provided to Administrator Mike Burstein.

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Sarah Benson	TELEPHONE: 530-895-5033
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023

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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Document Has Been Signed on 06/21/2023 11:03 AM - 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: 06/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(a)(11)

This requirement is not met as evidenced by: Two employee files did not have TB test recorded.
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/28/2023
	Plan of Correction
1 2 3 4	Appointment will be made for employees to get T.B test by 06-28-2023. All employee files will have T.B. test recorded. A resource guild for employee file requirements has been emailed to Administrator.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 06/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023

LIC809 (FAS) - (06/04)

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