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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 576804173
Report Date: 11/05/2024
Date Signed: 11/05/2024 12:16:07 PM

Document Has Been Signed on 11/05/2024 12:16 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:
9163731591
CITY:WEST SACRAMENTOSTATE: CAZIP CODE:
95691
CAPACITY: 43CENSUS: 29DATE:
11/05/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Maria Ortiz, Resident Care Coordinator TIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
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On November 5, 2024, Licensing Program Analyst (LPA)Jill Nakagawa arrived unannounced to conduct a Post-Licensing inspection for Grand River Villa. LPA met with Maria Ortiz, Resident Care Coordinator. There are currently 29 residents at this Resident Care Facility for the Elderly, with an approved fire clearance for 43 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 10/23/2024 and fully charged.

LPA inspected the grounds of the facility and found them to be well-maintained. A recent fire of the storage shed in the back yard was completely cleaned up and all debris removed. No damage to facility occurred.

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. There was not an adequate supply of perishable and non-perishable foods as required per regulation(See 809-D). Bathrooms had slip mats and grab-bars for resident safety. Hand soap is supplied for handwashing. New paper towel dispensers are being installed in each resident restroom to replace other means. Water temperature was between 105 - 115 degrees F, which is within regulation.

A tour of residents' bedrooms was conducted and bedrooms inspected have lighting and appropriate furnishings and linens.

LPA observed the Let Us Know Complaint poster and See Something Say Something poster. Updated Emergency Disaster Plan and Administrator Certificate to be posted.

Continued on 809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2024
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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Document Has Been Signed on 11/05/2024 12:16 PM - It Cannot Be Edited


Created By: Jill Nakagawa On 11/05/2024 at 11:11 AM
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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: GRAND RIVER VILLA
FACILITY NUMBER: 576804173

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/05/2024
Section Cited
CCR
87555(b)(26)

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87555 General Food Service Requirements (b) The following food service requirements shall apply:(26)Supplies of nonperishable foods for a minimum of one week.. perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by:
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Licensee to submit proof of purchase of food by 11/07/24 to LPA to ensure adequate food supply ison site of facility.
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Based on LPA's observation Licensee failed to ensure that there were adequate perishable and non-perishable foods available for the required time frame for a minimum of 29 residents.
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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:Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:
DATE: 11/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/05/2024


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: 11/05/2024
NARRATIVE
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Continued from 809....

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview was conducted with Administrative Assistant and a copy of this report was given.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2024
LIC809 (FAS) - (06/04)
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