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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 577000418
Report Date: 03/03/2022
Date Signed: 03/03/2022 11:18:23 AM


Document Has Been Signed on 03/03/2022 11:18 AM - 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: 24DATE:
03/03/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Maria Ortiz, Med Tech. and Diana Paz, Administrator, via phoneTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Jill Nakagawa conducted an unannounced Case Management- Incident Inspection and met with Maria Ortiz, Med Tech. and Administrator, Diana Paz, via phone. LPA arrived to facility and contacted Administrator. The purpose of this case management inspection was to follow up on self-reported incident report submitted to Community Care Licensing (CCL).

The incident of 02/28/22 was reported on 03/01/22, regarding inappropriate behavior between R1 and R2. During visit LPA gathered records, took statements from Administrator and staff. Facility has been in contact with Police, CCL and Ombudsmans' Office.


No deficiencies cited during this inspection.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 03/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2022
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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