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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803301
Report Date: 10/19/2021
Date Signed: 10/20/2021 11:28:15 AM

Document Has Been Signed on 10/20/2021 11:28 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
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:GRANADA HILLS MANORFACILITY NUMBER:
486803301
ADMINISTRATOR:GUINTO, JOY J.FACILITY TYPE:
740
ADDRESS:1442 GRANADA STREETTELEPHONE:
(707) 651-9299
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 6CENSUS: 5DATE:
10/19/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:52 PM
MET WITH:Dante GuintoTIME COMPLETED:
06:00 PM
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Licensing Program Analyst (LPA) A. Canela arrived at the facility unannounced to investigate a complaint that was recently received.

LPA toured the home and observed a bottle of liquid Clorox in room #1 accessible and not locked. A bottle of Clorox spray was also observed in the living room area. A bottle of arthritis liquid and a pair of scissors were observed in room #4. Several bottles of medication were observed in room #2. Facility has at least 3 residents with Dementia and medication, cleaning supplies or sharps should not be accessible to residents. LPA also observed both the dining sliding door and the sliding door to room #1 with the auditory alarms turned off and facility cares for residents with Dementia.
The main bathroom was observed to require cleaning of the walls, floor, sink and shower. The facility hallway trim is in need of cleaning as well as all the kitchen cabinets. Kitchen sink cabinet will need to be repaired as it shows water damage and signs of mold. Dining sliding door screen will need to be adjusted or corrected to open and close properly.

The following deficiencies were observed (see LIC 809-D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights and this report will be emailed to facility due to printer problems.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2021
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 10/20/2021 11:28 AM - It Cannot Be Edited


Created By: Araceli Canela On 10/19/2021 at 05:12 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: GRANADA HILLS MANOR
FACILITY NUMBER: 486803301

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/21/2021
Section Cited

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87705(f)(2) Care of Persons with Dementia The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
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This requirement was not met, based on todays facility inspection, LPA observed medication accessible in resident R1 and R4. LPA also observed bottles of Clorox not locked and a pair of scissors in R1s room. This is an immediate risk to residents in care.
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To LPA Araceli Canela
Type A
10/21/2021
Section Cited

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87705(j) Care of Persons with Dementia The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.
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This requirement was not met, as evidenced by: Upon arrival facility did not have some auditory alarms turned on in dining room sliding door and sliding door in room #1 and door in room #3. Facility has residents diagnosed with Dementia.
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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:Kimberley Mota
LICENSING EVALUATOR NAME:Araceli Canela
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/20/2021 11:28 AM - It Cannot Be Edited


Created By: Araceli Canela On 10/19/2021 at 05:22 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: GRANADA HILLS MANOR
FACILITY NUMBER: 486803301

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/05/2021
Section Cited

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87303(a) Maintenance and Operation(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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This requirement was not met as evidenced by todays inspection. LPA observed main hall way bathroom in need of cleaning (walls, floor, sink, shower) . Hallway floor trims need cleaning. Kitchen sink cabinet shows water damage and dining screen door needs repair. This is a potential risk to the health and safety of residents in care.
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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:Kimberley Mota
LICENSING EVALUATOR NAME:Araceli Canela
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2021


LIC809 (FAS) - (06/04)
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