<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800457
Report Date: 12/12/2023
Date Signed: 12/12/2023 11:58:26 AM


Document Has Been Signed on 12/12/2023 11:58 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:GRANADA MANORFACILITY NUMBER:
496800457
ADMINISTRATOR:ILAN, CHEYFACILITY TYPE:
740
ADDRESS:4760 GRANADA DR.TELEPHONE:
(707) 539-7059
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY:6CENSUS: 5DATE:
12/12/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Chey Ilan, AdministratorTIME COMPLETED:
12:13 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a Case Management- POC and was greeted by Chey Ilan, Administrator and Clayton Anderson, Licensee. Facility currently has five (5) residents in care.

On 11/07/2023 facility was cited for not complying with Title 22 regulation 87705(5) in [3] out of [5] resident records with a diagnosis of dementia, their respective LIC602s were not current within 12 months. LPA discussed with Administrator failure to satisfy plan of correction by due date of 11/28/2023. As of today, the respective LIC602s have not been made current and as such the plan of correction (POC) to correct deficiency has not been corrected. A civil penalty of $100 per day shall be assessed beginning the day after the POC due date of 11/29/2023. The Civil Penalty will continue to accrue at $100 per day until the deficiency is corrected.

On 11/07/2023 LPA requested facility send updated LIC500 within 30 days. As of today, 12/12/2023 updated LIC500 has not been received by CCLD. Per LPA interview with Administrator, the only staff currently working with residents are herself and Clayton Anderson, Licensee. Administrator confirmed there are no overnight awake staff currently working. Per Title 22, regulation 87705(c)(4)(A) Care of Persons with Dementia - Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. (A) In addition to requirements specified in Section 87415, Night Supervision, a facility with fewer than 16 residents shall have at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal, reappraisal or observation to require awake night supervision (deficiency cited, see 809D).

Per LPA interview with Administrator, the only staff currently working with residents is herself and Clayton Anderson, Licensee; however, Licensee does not have current training hours completed. Per Title 22, regulation 87411(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (deficiency cited, see 809D).

Continued on 809C...

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: GRANADA MANOR
FACILITY NUMBER: 496800457
VISIT DATE: 12/12/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from 809...

Per LPA interview with Administrator and Licensee, the room on facility sketch designated as a commonly used living room is currently being used as a sleeping room for non-client resident (NCR1). Per Title 22, regulation 87307(a)(2)B) Personal Accommodations and Services- No room commonly used for other purposes shall be used as a sleeping room for any resident. This includes any hall, stairway, unfinished attic, garage storage area, shed or similar detached building (deficiency cited, see 809D)

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:


LIC500- Personnel Report
Copy of Deed or Mortgage

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Licensee. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.
Exit interview conducted with Administrator and a copy of this report was given.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 12/12/2023 11:58 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: GRANADA MANOR
FACILITY NUMBER: 496800457

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/20/2023
Section Cited
CCR
87307(a)(2)B)

1
2
3
4
5
6
7
87307(a)(2)B) Personal Accommodations and Services - No room commonly used for other purposes shall be used as a sleeping room for any resident. This includes any hall, stairway, unfinished attic, garage storage area, shed or similar detached building.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Facility to submit updated facility sketch with room currently designated as living room updated to show it is a sleeping room for NCR1. Facility to submit by POC date of 12/20/2023. Once updated facility sketch received, CCLD will submit request for fire clearance.
8
9
10
11
12
13
14
Based on LPA and Administrator interview, the licensee did not comply with the section cited above as resident (NCR1) is currently using room designated as living room as a sleeping room, which poses a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Type B
01/03/2024
Section Cited
CCR87411(c)

1
2
3
4
5
6
7
87411(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator to provide proof of completed required trainings for Licensee, Clayton Anderson by POC due date of 01/03/2023.
8
9
10
11
12
13
14
Based on LPA and Administrator interview, Licensee provides care to residents but has not completed required trainings. Required trainings not current.
8
9
10
11
12
13
14
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: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 12/12/2023 11:58 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: GRANADA MANOR
FACILITY NUMBER: 496800457

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/09/2024
Section Cited
CCR
87705(c)(4)(A)

1
2
3
4
5
6
7
 87705(c)(4)(A)Care of Persons with Dementia Licensees who retain residents with dementia shall be responsible for ensuring the following:...have at least one night staff person awake and on duty...

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator to hire staff, ensuring at least one night staff person is awake and on duty. Administrator to provide proof to CCLD that hired staff has completed all required trainings, obtained background and fingerprint clearance, and are associated to the facility before working with clients in any capacity.
8
9
10
11
12
13
14
Based on LPA and Administrator interview the only staff currently working with residents are herself and Clayton Anderson, Licensee. Administrator confirmed there are no overnight awake staff currently working.
8
9
10
11
12
13
14
Proof to be submitted by POC due date of 1/9/2023.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4