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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 577000418
Report Date: 09/15/2020
Date Signed: 09/21/2020 07:54:20 AM

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:
09/15/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Dana SbarroTIME COMPLETED:
04:59 PM
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Licensing Program Analyst LPA Walters spoke with Administrator, Dana Sbarbaro via teleconference in order to conduct a Case Management inspection. LPA was unable to conduct an in person visit due to COVID-19 precautions.

LPA is following up on a report made to CCL that S1 was smoking inside the facility. At approximately 3:20 PM, LPA toured the facility with Administrator. At 3:25 PM LPA observed that the facility had a designated smoking area outside of the facilities EXIT. LPA advised that the smoking area be moved away from the building. DS agreed to moving smoking area away from the building and adding a canopy for residents. LPA and Administrator continued tour. At 3:31 PM Staff tested the smoke alarm in the dinning room of the facility and it was found to be operational. Two of the other twelve smoke alarms were not operational. LPA also learned that there is a resident in the facility who uses oxygen. The Administrator stated that S1 was smoking at the back door of the kitchen.

An exit interview was conducted at 4:40 PM. DS agreed to moving the designated smoking area away from the building and creating a smoking policy. In addition, the Administrator will also chart that the staff are checking smoke/carbon monoxide alarms monthly. Administrator will send proof of these changes to LPA by 9/21/2020. LPA addressed the risk of smoking in doors and when oxygen is in use.

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

DATE: 09/15/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2020
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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