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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 577000418
Report Date: 07/10/2020
Date Signed: 07/10/2020 07:38:26 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:GRAND RIVER CARE CENTER-WESTFACILITY NUMBER:
577000418
ADMINISTRATOR:DANA SBARBAROFACILITY TYPE:
740
ADDRESS:509 MICHIGAN BOULEVARDTELEPHONE:
(916) 373-1591
CITY:WEST SACRAMENTOSTATE: CAZIP CODE:
95691
CAPACITY:30CENSUS: DATE:
07/10/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:33 PM
MET WITH:Caroline DeguzemanTIME COMPLETED:
05:49 PM
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On 7/10/20 at approximately 3:30 PM LPA Walters conducted a Case Management- Incident tele-visit with Administrator, Caroline Deguzeman. Case management was conducted by tele-visit due COVID-19 restrictions. LPA toured the facility and interviewed staff.

On 6/29/20 the facility self-reported incident involving Resident R1. Incident report indicated that during a room audit facility staff found medication that R1’s family member had provided resident without notifying facility. The medication was removed. Staff notified Nursing Director, Nisha Kuar. The responsible parties were notified of protocol. The physician was notified. LPA interviewed Administrator/ Staff and toured facility. LPA determined that the facility has made on-going efforts to prevent.


No deficiencies are being cited at this time.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina WaltersTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2020
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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