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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 577000418
Report Date: 08/03/2022
Date Signed: 08/03/2022 04:08:00 PM


Document Has Been Signed on 08/03/2022 04:08 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: DATE:
08/03/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Diana Paz, AdministratorTIME COMPLETED:
04:10 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to inspect facility and check on the proceedings of eviction notice of resident. LPA was met at door by carestaff who performed Covid-19 screening and took LPA's temperature. After LPA logged in all required information entry to the facility was allowed.

LPA found the facility to be clean and a comfortable temperature, despite it being well over 100 degrees at the time of visit. Residents were resting in their rooms, as it was quite warm to be outside at this time. LPA learned that there are hydration breaks for residents at 10,2 and 7, with water available at all times. Many residents were found to have water pitchers in their rooms on bedside tables.

Administrator reviewed the eviction proceedings thus far, ensuring that all regulations are being followed. Eviction notice was sent out due to non-payment of rent from the time of admission until now. There has been no response to facility from the responsible party. A copy of the eviction notice was sent via Certified Mail on 7/7/22. Administrator has been keeping APS and Ombudsman informed.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2022
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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