577000418-8-14-2023-21-AS-FSAI-CUPUKY-20230814153954

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 577000418
Report Date: 08/14/2023
Date Signed: 08/14/2023 03:40:26 PM

Document Has Been Signed on 08/14/2023 03:40 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-WEST		FACILITY NUMBER:	577000418
ADMINISTRATOR:	PAZ, DIANA		FACILITY TYPE:	740
ADDRESS:	509 MICHIGAN BOULEVARD		TELEPHONE:	(916) 373-1591
CITY:	WEST SACRAMENTO	STATE: CA	ZIP CODE:	95691
CAPACITY:	30	CENSUS: 28	DATE:	08/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Administrator, Diana Paz		TIME COMPLETED:	03:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Grand River Care Center-West for the purpose of conducting a Required 1 year inspection. LPA was greeted at the door by, Administrator, Diana Paz, and was granted access into the facility. During the Required 1 year inspection and checking of background clearances, Administrator confirmed an Excluded Staff Member is not working in the facility or residing in the facility. Administrator disclosed that the individual was prospective, but was never hired on. LPA obtained a copy of the LIC 500 and the staff schedule. Excluded Staff Member was not seen on the premises. Based on evidence obtained during today’s Required 1 year inspection, the LPA has verified Excluded Staff Member is not present, employed, or residing at the facility. Verification of removal is complete. LPA and Administrator toured the one story facility. LPA observed the facility to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguishers were found to be last charged in October 2022, March 2023 and July 2023 at the time of the inspection. All smoke detectors and carbon monoxide detectors sound directly to the fire station. Auditory Devices were operational during the Required 1 year inspection. First Aid kit was inspected and found to be appropriate during the inspection. Water temperature in a sample of 4 of 4 residents bathroom measured at 115 degrees and is within acceptable range of 105 to 120 degrees F. There was sufficient perishable and non-perishable foods located in the kitchen. Knives and other hazardous items were locked and inaccessible to residents in care. There are special provisions made for individuals with special dietary needs. Food and Activity menu was presently available for viewing during the inspection. Cleaning products and other toxins are located in the locked laundry room and inaccessible to residents in care. There was a supply of Linens, cleaners, hygiene products and paper products available for residents in care during the inspection. All bathrooms designated for residents in the common areas at the facility were supplied with individual paper towels and hand soap. (Report continued on LIC 809C)

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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-WEST	FACILITY NUMBER: 577000418
	VISIT DATE: 08/14/2023

NARRATIVE

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Bathrooms in resident’s rooms have a towel and soap. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. A tour of all residents bedrooms were conducted, and bedrooms inspected have lighting and appropriate furnishing.

Facility Infection Control Plan, emergency disaster plan and staff files will be reviewed at a later date and time. Staff interviews will also be conducted at a later date and time. No deficiencies were observed or cited during today's Required 1 year inspection. Exit interview was conducted and a copy of this report was given to the Administrator.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2023

LIC809 (FAS) - (06/04)

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