079200598-4-30-2025-15-AS-CFOR-DG92AJ-20250430171337

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200598
Report Date: 04/30/2025
Date Signed: 04/30/2025 05:13:53 PM

Document Has Been Signed on 04/30/2025 05:13 PM - 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 1		FACILITY NUMBER:	079200598
ADMINISTRATOR/ DIRECTOR:	LI, FEI KEVIN		FACILITY TYPE:	740
ADDRESS:	2359 GRANADA COURT		TELEPHONE:	(510) 758-9888
CITY:	PINOLE	STATE: CA	ZIP CODE:	94564
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	04/30/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:15 PM
MET WITH:	CORAH NUFABLE, CARE STAFF		TIME VISIT/ INSPECTION COMPLETED:	05:40 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	On 4/30/2025 at 9:30am, Licensing Program Analyst (LPA) Carol Fowler conducted an unannounced 1-Year Required inspection. LPA met with Fei Kevin Li, Administrator and explained the purpose of the visit. The Administrator currently holds a certificate (#7035708740) that expires on 07/26/2026. The facility’s fire clearance was approved for six (6) non-ambulatory residents. LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, garage and backyard. The facility consists of four (4) total bedrooms, which one (1) bedroom is occupied by staff, and two (2) bathrooms. No bodies of water observed. A comfortable temperature is maintained at 72 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 106.4 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 01/30/2025. Emergency Disaster Plan is not posted. First aid kit was observed to be complete. LPA reviewed two (2) staff files and all three (3) resident files which were all complete. Continued on LIC809C.

Bennett Fong	TELEPHONE: (510) -62-2621
Carol Fowler	TELEPHONE: (510) 622-2715
	DATE: 04/30/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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 1	FACILITY NUMBER: 079200598
	VISIT DATE: 04/30/2025

NARRATIVE

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Continue from LIC 809

LPA requested the following documents to be submitted to CCLD by 05/09/2025.

· LIC 308 Designation of Administrative Responsibility
· LIC 309 Administrative Organization
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan
· Liability Insurance

LPA observed the following deficiencies:

At 2:44pm, LPA observed slow water flow, chipped, cracked and rusted tile in bathroom #1.
At 2:55pm, LPA observed back yard porch ladder, bed frame, mattress, commodes, end table, lamp, bed rails, ladder, sink, washer, walker, paint buckets, toilet, chairs, cart, fan, bricks, gas can,
At 3:05pm, LPA observed no screen on back sliding door.
At 3:15pm, LPA observed cobwebs and dirty curtains on the large window/sliding back door.
At 3:20pm, LPA observed a leak under the kitchen sink.

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of appeal rights and this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 04/30/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/30/2025 05:13 PM - 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 1	FACILITY NUMBER: 079200598
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87303(c)

(c) All window screens shall be clean and maintained in good repair. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having a missing screen door which poses a potential health and safety risk to persons in care.
	POC Due Date: 05/14/2025
	Plan of Correction
1 2 3 4	Administrator agreeded to get a screen door for the sliding glass door and provide photos to the Department by the POC date.

Type B

Section Cited

CCR

87307(d)(4)

(4) Stairways, inclines, ramps and open porches and areas of potential hazard to residents with poor balance or eyesight shall be made inaccessible to residents unless equipped with sturdy hand railings and unless well-lighted. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having a ladder, bed frames, mattress, commodes, end table, lamp, sink washer, walkers, paint buckets, toilet, chairs, cart, fan bricks and a gas can located in open porch and in the back yard which poses a potential health and safety risk to persons in care.
	POC Due Date: 05/14/2025
	Plan of Correction
1 2 3 4	Administrator agreed to remove ladder, bed frames, mattress, commodes, end table, lamp, sink washer, walkers, paint buckets, toilet, chairs, cart, fan bricks and a gas can which poses a potential health and safety and submit photos to CCLD by the POC date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Bennett Fong	TELEPHONE: (510) -62-2621
Carol Fowler	TELEPHONE: (510) 622-2715
	DATE: 04/30/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/30/2025 05:13 PM - 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 1	FACILITY NUMBER: 079200598
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87303(a)

Maintenance and Operation 87303(a) (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having cobb webbs with dirty curtains located in the living room, hot water slow flow of water, missing, cracked and rusted tile in bathroom #1 and a leak under the kitchen sink which poses a potential health and safety risk to persons in care.
	POC Due Date: 05/14/2025
	Plan of Correction
1 2 3 4	Administrator agreed to clean the windows, clear the cobb webbs and wash the curtains, repair and/or replace the tile and rust, repair the flow of water and repair the leak under the kitchen sink and provide CCLD with photo copies no later than the POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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.

Bennett Fong	TELEPHONE: (510) -62-2621
Carol Fowler	TELEPHONE: (510) 622-2715
	DATE: 04/30/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2025

LIC809 (FAS) - (06/04)

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