079200598-9-24-2023-15-AS-LHAL-CVYVLZ-20230924163245

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200598
Report Date: 09/24/2023
Date Signed: 09/24/2023 04:32:58 PM

Document Has Been Signed on 09/24/2023 04:32 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:	LI, FEI KEVIN		FACILITY TYPE:	740
ADDRESS:	2359 GRANADA COURT		TELEPHONE:	(510) 758-9888
CITY:	PINOLE	STATE: CA	ZIP CODE:	94564
CAPACITY:	6	CENSUS: 6	DATE:	09/24/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Reggielyn Daigdigan, Caregiver		TIME COMPLETED:	04:50 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 9/24/2023 at 1:30pm, Licensing Program Analyst (LPA) L. Hall conducted an unannounced 1-Year Required inspection. LPA met with Reggielyn Daigdigan, Caregiver, and explained the purpose of the visit. Kevin Li, Administrator arrived at 1:50pm. The Administrator currently holds a certificate (#6040792740) that expires on 07/26/2024. The facility’s fire clearance was approved for six (6) non-ambulatory residents. LPA toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area, garage and backyard. The facility consists of four (5) 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 133.1 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 04/27/2023. Emergency Disaster Plan was last posted on 5/17/2018. First aid kit was observed to be complete. LPA reviewed three (3) staff files and all did not have current first aid certification. Continued on LIC809C.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2023

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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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: 09/24/2023

NARRATIVE

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Continued from LIC809.

LPA reviewed all six (6) resident files and three (3) of six (6) did not have a current appraisal needs and services plan.

LPA observed the following deficiencies:

At 1:35pm, LPA observed S3 was not associated to the facility.
At 1:40pm, LPA observed flip door lock at top of front door.
At 1:50pm, LPA observed hot water in shared bathroom measuring at 133.1 degrees F.
At 1:55pm, LPA observed that R2, R3, R4, and R5 did not have a doctor's order for bedrails.
At 2:15pm, LPA observed during record review R2, R3, and R5 did not have a current appraisal needs and services plan.
At 2:30pm, LPA observed a pile of cardboard boxes, a fan, a sink, chairs, a night stand, wheelchairs, walkers, a lamp and other items in back yard.
At 2:35pm, LPA observed shed in back yard being used as a living quarters.
At 3:00pm, LPA observed during record review that none of the staff have first aid or CPR certification.

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: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/24/2023 04:32 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: 09/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(3)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs. 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 in having hot water measure between 105 to 120 which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/25/2023
	Plan of Correction
1 2 3 4	Administrator agreed to submit photo to CCLD showing hot water between 105-120 by POC date.

Type A

Section Cited

CCR

87355(e)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in having staff associated to facility which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/25/2023
	Plan of Correction
1 2 3 4	Administrator agreed to submit LIC9182 and identification of staff to CCLD by POC to associate staff.

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: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/24/2023 04:32 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: 09/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87305(a)

Alterations to Existing Buildings or New Facilities

Prior to construction or alterations, all facilities shall obtain a building permit. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in having the shed in back yard fire cleared for staff living quarters which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/02/2023
	Plan of Correction
1 2 3 4	Administrator agreed to submit and LIC200 and updated facility sketch to CCLD by POC date.

Type B

Section Cited

CCR

87307(d)(6)

Personal Accommodations and Services

(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. 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 in having a pile of cardboard boxes, wheelchair, walkers, lamp, sink and other items in back yard which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/02/2023
	Plan of Correction
1 2 3 4	Administrator agreed to have items in back yard removed and submit photo to CCLD by 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.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/24/2023 04:32 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: 09/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.618(c)(3)

Other Provisions

(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in having at least 1 staff with first aid and CPR which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/02/2023
	Plan of Correction
1 2 3 4	Administrator agreed to have staff first aid certified and at least 1 staff CPR certified and submit copies of certification to CCLD by POC date.

Type B

Section Cited

CCR

87463(c)

Reappraisals

(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in having current appraisal needs and services plan for 3 of the residents which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/02/2023
	Plan of Correction
1 2 3 4	Administrator agreed to complete the appraisal needs and services plan for residents and submit a self-certification that it has been completed to CCLD by 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.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/24/2023 04:32 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: 09/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87468.1

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This does not prohibit a licensee from establishing house rules, such as locking doors at night to protect residents, or barring windows against intruders, with permission from the Department. 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 in having a flip door latch on front door which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/25/2023
	Plan of Correction
1 2 3 4	Administrator agreed to remove latch and submit a photo to CCLD by 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.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/24/2023 04:32 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: 09/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87608(a)(3)

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in having doctor orders for half-bed rails which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/02/2023
	Plan of Correction
1 2 3 4	Administrator agreed to obtain doctor orders for half-bed rails for residents by 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.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2023

LIC809 (FAS) - (06/04)

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