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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200596
Report Date: 05/20/2022
Date Signed: 05/20/2022 11:57:44 AM


Document Has Been Signed on 05/20/2022 11:57 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:GRANADA CARE HOME NO 2FACILITY NUMBER:
079200596
ADMINISTRATOR:LI, FEI KEVINFACILITY TYPE:
740
ADDRESS:2360 GRANADA COURTTELEPHONE:
(510) 758-9888
CITY:PINOLESTATE: CAZIP CODE:
94564
CAPACITY:6CENSUS: 6DATE:
05/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Fei Kevin Li, AdministratorTIME COMPLETED:
12:35 PM
NARRATIVE
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On 5/20/2022 at 11:15 am, Licensing Program Analyst (LPA) C. Fowler arrived unannounced to conduct an Infection Control Inspection. LPA met with Administrator, Fei Kevin Li and Caregiver Reggielyn Daigdigan and explained the purpose of the visit. LPA toured facility after touring Granada #1 because Administrator had to leave and approved Caregiver to sign documents.

Upon entry, LPA observed screening station that contained hand sanitizer, thermometer and COVID-19 signage. LPA toured facility including but not limited to common areas, bathrooms, bedrooms, kitchen, and backyard. LPA observed cough etiquette and physical distancing posted in the common areas. All hand washing stations were equipped with soap, paper towel, and hand washing posters.

During record review, LPA observed visitors log and temperature logs for residents or staff. LPA observed facility has a copy of Mitigation Plan on file.

The following deficiencies were observed during the visit:

-At 9:28am, LPA observed a small room built in the garage which is not on the facility sketch.
-At 9:30am, LPA observed scissors in a unlocked drawer in the kitchen.
-At 9::32am, LPA observed medication in an unlocked cabinet.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2022
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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Document Has Been Signed on 05/20/2022 11:57 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: GRANADA CARE HOME NO 2
FACILITY NUMBER: 079200596

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)(2)
87705 Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia:
(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
(2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having scissors in an unlocked draw and having medication cabinet unlocked which poses an immediate health and safety risk to persons in care.
POC Due Date: 05/21/2022
Plan of Correction
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Administrator locked the medication cabinet and had Caregiver lock the scissors. Deficiency cleared during visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4

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: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 05/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3


Document Has Been Signed on 05/20/2022 11:57 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: GRANADA CARE HOME NO 2
FACILITY NUMBER: 079200596

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87305(A)
87305 (A)

Alterations to Existing Building or New Facilities

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on, the licensee did not comply with the section cited above by building a small room in the garage which poses a potential health and safety risk to persons in care.
POC Due Date: 06/20/2022
Plan of Correction
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Administrator agreed to provide CCLD with a copy of a building permit for the small room built in the garage no later than the POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4

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: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 05/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3