496804250-9-6-2024-21-AS-CCOO-D8UUZ7-20240906160105

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496804250
Report Date: 09/06/2024
Date Signed: 09/06/2024 04:01:22 PM

Document Has Been Signed on 09/06/2024 04:01 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	GRAND CRU SENIOR CARE CORP		FACILITY NUMBER:	496804250
ADMINISTRATOR:	SEKHON, TEJPAL		FACILITY TYPE:	740
ADDRESS:	2540 SUMMERFIELD RD		TELEPHONE:	(530) 218-2371
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95405
CAPACITY:	6	CENSUS: 5	DATE:	09/06/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	11:35 AM
MET WITH:	Tejpal Sekhon, Administrator		TIME COMPLETED:	04:15 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 pre-licensing inspection and was greeted by caregiver. Facility Administrator, Tejpal Sekhon arrived later at approximately 12:00pm. Facility currently has five residents in care. At approximately 12:00pm LPA toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed within regulation emergency supply of non-perishable food. Kitchen has locked cabinet that stores toxins and cleaning products. One locked drawer is dedicated for sharp knives. Facility is a one story residence with six bedrooms, two full and one half bathrooms, and dining and living room common areas. All resident rooms are furnished per regulation with a bed, lamp, dresser, chair and bedside table. Facility does not have central air but has two portable air coolers. The living room and rooms one, two, five, and six all have ceiling fans. Administrator to have fans available in all bedrooms before licensing. Room four has a hole on the east wall that needs repair. Smoke and carbon monoxide detectors present and functioning. Facility has two fire extinguishers present and charged. Emergency lighting needed in hallway. LPA observed all required postings and posters present. Administrator advised that facility will coordinate with local services to provide emergency transport services in the event of a disaster. Water temperatures read at: 108 F in kitchen, 105.5 F in main bath, 106 F in room one, 112 F in back half bath by rooms five and six, all which are within regulation of 105 & 120 degrees F. Report continued on 809C...

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi Coppo	TELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024

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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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: GRAND CRU SENIOR CARE CORP	FACILITY NUMBER: 496804250
	VISIT DATE: 09/06/2024

NARRATIVE

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Continued form 809...

The following items to be corrected prior to LPA submission of facility's application for approval:

Right door on kitchen cabinet on right side of refrigerator broken, needs to be repaired
Right door of kitchen cabinet under the sink broken, needs to be repaired
Street-facing front portion of fence missing a board and loose board leaning against fence. All loose boards to be removed and gap spaces repaired
Overgrown weeds and debris present on front facing east side of yard. Weeds and debris need to be removed and facility to ensure landscaping is safe for residents in entire back yard
Fence and fence door surrounding garden area in back yard needs to be repaired/replaced such that it is safe for residents; no exposed screws. Fence has broken, half detached boards that must be replaced/repaired
Main deck south side gate door needs to be replaced/repaired such that is closes properly and latches properly when closed. Currently, it does not latch and gate does not close without lifting it up and over the bottom portion of the deck.
South side back half of perimeter fence is leaning and cannot bear weight safely. Facility to replace/repair back half of perimeter fence so that it is structurally sound and secure for residents
Room four has a hole on the east wall that needs repair.
Night lights present in hallway

LPA reviewed staff and resident files. The following items to be corrected prior to LPA submission of facility's application for approval: Appraisals/Care Plans for all residents to be current. CPR for all staff to be current.

Administrator to provide photos and/or videos of repaired/replaced items. Once acceptable photographic and/or video proof of corrections is received by CCL, LPA will submit facility's application for approval.

Comp III reviewed and exit interview conducted with Administrator and a copy of this report given.

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi Coppo	TELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024

LIC809 (FAS) - (06/04)

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