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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 577000418
Report Date: 09/10/2021
Date Signed: 09/10/2021 05:35:50 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:
09/10/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:18 PM
MET WITH:Diana PazTIME COMPLETED:
05:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Karina Canela arrived to Grand River Care Center-West facility unannounced regarding a complaint investigation. Upon arrival, LPA was met at the door by Individual (I1), and staff. I1 and staff wore masks and were providing care/assistance to residents in the facility. Administrator Diana Paz arrived later.
LPA verified through the facility Guardian Personal Report/Roster that I1 had a fingerprint clearance but was not associated to Grand River Care Center-West as required. Interviews revealed I1 began working at Grand River Care Center-West on 09/10/2021.

LPA explained prior to anyone working (including shadowing a staff and/or training), volunteering, residing or being present in any part of the licensed facility they are required to be fingerprint cleared and associated to the facility. LPA explained Community Care Licensing (CCL) requirements and provided the regulation.

Administrator stated they understood CCL's requirements and prior to anyone working, providing care, volunteering, or residing at Grand River Care Center-West, the individual must obtain a fingerprint clearance and be associated to the facility.


Civil penalty in the total amount of $100.00 was issued today for individual (I1) not being associated to this facility as required.

Appeal Rights Provided.
Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Diana Paz, Administrator, who's signature below confirms receipt of report.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Karina CanelaTELEPHONE: 707-588-5054
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2021
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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-WEST
FACILITY NUMBER: 577000418
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/10/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
09/11/2021
Section Cited

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87355 (e)(2) - Criminal Record Clearance
(e) All individuals subject to a criminal record review...(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance...

This requirement was not met as evidenced by:
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Based on record review, observations, and interviews conducted: Administrator did not request a transfer of a criminal record clearance for individual (I1) prior to working at the facility.
This is an immediate safety risk to the residents in care.
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**Civil Penalty assessed in the amount of $100.00

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Karina CanelaTELEPHONE: 707-588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 09/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2021
LIC809 (FAS) - (06/04)
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