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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 577000418
Report Date: 06/21/2022
Date Signed: 06/21/2022 11:07:04 AM


Document Has Been Signed on 06/21/2022 11:07 AM - 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: DATE:
06/21/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Diana Paz, AdministratorTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct an inspection regarding a case management involving the possibility of an eviction. LPA was met at the door after going through a screening for Covid-19 symptoms and using handsanitizer.

LPA met with Administrator Diana Paz who conducted a tour of the facility. Facility was clean and a comfortable temperature. The facility was ready for hot weather and has hydration/snack breaks scheduled throughout the day in addition to water being available to residents at all times. Activities have resumed, and several residents were participating in an exercise class (while practicing social distancing) during LPA's visit.

LPA and Administrator discussed a possible eviction in the future. Licensee and Administrator are working with the family to explore possible options. Communication between all parties has been ongoing for several months. APS and Ombudsman are aware of the situation. Administrator will keep CCL informed of any further developments.

There were no deficiencies cited during this visit.



SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2022
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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