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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 576804173
Report Date: 11/14/2024
Date Signed: 11/14/2024 03:27:26 PM

Document Has Been Signed on 11/14/2024 03:27 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/
DIRECTOR:		GODFREY, ROBERTFACILITY TYPE:
740
ADDRESS:509 MICHIGAN BLVDTELEPHONE:
(916) 373-1591
CITY:WEST SACRAMENTOSTATE: CAZIP CODE:
95691
CAPACITY: 43CENSUS: 29DATE:
11/14/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:40 PM
MET WITH:Maria Ortiz, Resident Care Coordinator and Robert Godfrey, Administrator via phoneTIME VISIT/
INSPECTION COMPLETED:
03:35 PM
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On 11/14/2024, Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced and was greeted by Resident Care Coordinator Maria Ortiz. The purpose of the visit is to follow up on the plan of correction for a previous deficiency and a health & safety check.

There are currently 29 residents under the facility's care.

LPA inspected the facility's kitchen and found an ample supply of perishable and non-perishable foods, as required per Title 22. Licensee provided visit by dietician to help in training dietary staff. The plan of correction for deficiency cited on 11/05/2024 has been met.


No deficiency cited.

Exit interview conducted with Maria Ortiz, Resident Care Coordinator for Robert Godfrey, Administrator.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2024
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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