<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 577000418
Report Date: 07/30/2021
Date Signed: 07/30/2021 02:48:25 PM

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:PAZ, DIANAFACILITY TYPE:
740
ADDRESS:509 MICHIGAN BOULEVARDTELEPHONE:
(916) 373-1591
CITY:WEST SACRAMENTOSTATE: CAZIP CODE:
95691
CAPACITY:30CENSUS: 16DATE:
07/30/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Diana Paz, AdministratorTIME COMPLETED:
02:50 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) Jill Nakagawa arrived unannounced to conduct an Annual Required Inspection and met with Diana Paz, Administrator. The annual inspection is focused on the Infection Control procedures and practices of this Residential Care Facility for the Elderly.

LPA observed a screening station at the entrance of facility which had hand sanitizer, a thermometer, and a sign-in sheet for visitors. Visitors are screened for COVID-19 symptoms (including temperature check) upon arrival to the facility. Staff and clients' temperatures are taken 2 to 3 times a day and are documented. LPA conducted a walk-through of the facility with Administrator and observed COVID-19 precaution postings at the entrance to building, in common areas and in public use bathrooms and staff lounge.
Staff clean and disinfect the facility daily. High touched surface areas are disinfected after each use. The facility has a designated visitation area, provides virtual visits and has a house phone for family to stay in contact with residents.

Administrator stated unvaccinated staff are tested twice a week. LPA observed 16 clients in care. Facility staff have completed training on infection prevention, symptoms, transmission and PPE use. N-95 respirator Fit testing is in process.
LPA observed a supply of PPE including gloves, face shields, N-95 respirators, surgical masks and gowns. All staff wore a face mask during this visit. The facility has submitted a COVID-19 Mitigation Plan Report on Epidemic Outbreaks specific to COVID-19 to the California Department of Social Services.

Exit interview conducted with Administrator, Diana Paz, whose signature on this document confirms receipt.



No deficiencies cited during this inspection.

Inspection Tool Notes:

Infection Control Practices - No Deficiency: 130 - Staff is in process of fit testing within 2-week time period through MNS.

SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1