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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 577000418
Report Date: 04/22/2022
Date Signed: 04/22/2022 01:02:25 PM


Document Has Been Signed on 04/22/2022 01:02 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 CARE CENTER-WESTFACILITY NUMBER:
577000418
ADMINISTRATOR:PAZ, DIANAFACILITY TYPE:
740
ADDRESS:509 MICHIGAN BOULEVARDTELEPHONE:
(916) 373-1591
CITY:WEST SACRAMENTOSTATE: CAZIP CODE:
95691
CAPACITY:30CENSUS: 22DATE:
04/22/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:03 PM
MET WITH:Diana Paz, Administrator via phone,
and Med Tech.		TIME COMPLETED:
01:05 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced for a Case Management visit to follow up on a possible eviction and past incident. LPA met with Med.Tech. and Administrator (via phone) and obtained copy of resident records and admission agreement, made observations and conducted interview with administrator and staff.

Prior conversation with Administrator Paz indicated that R1 had signed Admissions Agreement back on 12/16/2020, but facility was waiting on POA to sign. Letter to POA requested Agreement be signed and returned by 4/22/22 or eviction proceedings may be initiated.

Additionally, LPA was checking on residents from Incident on 2/28/22. Both residents from that Incident were no longer residents of the community.

No deficiencies cited during this inspection.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2022
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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