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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 576804173
Report Date: 07/29/2024
Date Signed: 07/29/2024 05:32:13 PM


Document Has Been Signed on 07/29/2024 05:32 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:GRAND RIVER VILLAFACILITY NUMBER:
576804173
ADMINISTRATOR:PAZ, DIANAFACILITY TYPE:
740
ADDRESS:509 MICHIGAN BLVDTELEPHONE:
(916) 373-1591
CITY:WEST SACRAMENTOSTATE: CAZIP CODE:
95691
CAPACITY:43CENSUS: 27DATE:
07/29/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
03:32 PM
MET WITH:Diana Paz, Administrator via phoneTIME COMPLETED:
05:35 PM
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Licensing Program Analyst (LPA)Jill Nakagawa arrived unannounced to conduct a Pre-Licensing inspection for Grand River Villa, previously Grand River Care Center-West. There are currently 27 residents at this Resident Care Facility for the Elderly, with an approved fire clearance for 36 non-ambulatory and 7 bedbound residents. It is a single story building with 23 rooms, an activity room, dining room, living room and enclosed backyard. There were no accessible bodies of water or firearms. The fire extinguishers were last inspected on 10/18/2023 and fully charged.

LPA observed locked box for knives and other sharps in the storage closet in the kitchen and a container in the medication room. Kitchen was clean and well-equipped with an adequate supply of dishes and utensils. Two refrigerators and one freezer were clean, with an adequate supply of perishable and non-perishable foods. Bathrooms had slip mats and grab-bars for resident safety. Hand washing supplies and paper products were available in sinks used by residents. Water temperature was between 112-116 degrees F, which is within regulation. A tour of residents' bedrooms was conducted and bedrooms inspected have lighting & appropriate furnishings and linens.

LPA observed the required postings including: emergency disaster plan, the Let Us Know Complaint poster and See Something Say Something poster.

Continued on 809-C
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2024
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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: GRAND RIVER VILLA
FACILITY NUMBER: 576804173
VISIT DATE: 07/29/2024
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Continued from 809....

A sample of 3 resident and 3 employee files were reviewed and found to be complete.

LPA waived the COMP 3 with ; some of Administrator as they have been with the facility for several years and has a good understanding of Title 22 regulations as well as reporting requirements. .

The pre-licensing evaluation has been completed. Applicant has satisfied all requirements in accordance with Title 22, California Code of Regulations. License will be granted upon completion of a final review and approval from the Licensing Program Manager.

This report will be forwarded to the Licensing Program Manager and Centralized Application Unit for continued processing.

This report was signed by Administrator's representative and a copy was provided.

No deficiencies were cited during today's visit.

SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024
LIC809 (FAS) - (06/04)
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