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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 577000418
Report Date: 09/30/2021
Date Signed: 10/04/2021 02:44:07 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
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:
09/30/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Mee ThaoTIME COMPLETED:
11:20 AM
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Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 09/30/2021 to continue the investigation for complaint received on 06/02/2021. Prior to visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; upon entry LPA completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask.

LPA was met by Medication Technician, Mee Thao. LPA explained that the reason for the visit was to conduct a resident interview of R1 for issues unrelated to this facility.

LPA met with R1.

There are no deficiencies noted as a result of this visit.

Due to technical issues, LPA was not able to leave a report with the facility. LPA spoke with Director, Diane Paz prior to departure.

Report emailed to Director for review and signature.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: 209-814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2021
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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