<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200596
Report Date: 06/29/2021
Date Signed: 06/29/2021 03:22:24 PM

Document Has Been Signed on 06/29/2021 03:22 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 2FACILITY NUMBER:
079200596
ADMINISTRATOR:LI, FEI KEVINFACILITY TYPE:
740
ADDRESS:2360 GRANADA COURTTELEPHONE:
(510) 758-9888
CITY:PINOLESTATE: CAZIP CODE:
94564
CAPACITY: 6CENSUS: 6DATE:
06/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Kevin Li, AdministratorTIME COMPLETED:
03:35 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 6/29/2021 at 12:50PM, Licensing Program Analysts (LPAs) G. Luk and C. Fowler arrived unannounced to conduct an Infection Control Inspection. LPAs met with Administrator, Kevin Li and explained the purpose of the visit.

LPAs toured facility including but not limited to bedrooms, bathrooms, kitchen, common areas, and outdoor areas. LPAs observed signs & symptoms posted in the common areas.

During record review, LPAs observed visitors log, but last visitation was documented on 5/2021. LPAs observed facility has a copy of Mitigation Plan on file. LPAs observed food and paper supplies are sufficient.

The following deficiencies were observed during the visit:
-At 12:58PM, LPAs observed unlocked medication in refrigerator.
-At 1:00PM, LPAs observed administrator did not have knowledge regarding CCLD regulations/PINs. Facility have not been documenting staff/resident temperature screening, entrance screen has not been done for visitors, no documentation of staff COVID-19 surveillance testing, CCLD postings (cough etiquette/hand washing) in common areas, and no gowns observed.
-At 1:10PM, LPAs observed facility did not document resident observation regularly.

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.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 06/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/29/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
Document Has Been Signed on 06/29/2021 03:22 PM - It Cannot Be Edited


Created By: Grace Luk On 06/29/2021 at 02:19 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 06/29/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

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 unlocked medication in the refrigerator which poses an immediate health and safety risk to persons in care.
POC Due Date: 06/30/2021
Plan of Correction
1
2
3
4
Administrator will lock medication in a lockbox prior to putting it in the refridgerator. Administrator will submit picture 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
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2021


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 06/29/2021 03:22 PM - It Cannot Be Edited


Created By: Grace Luk On 06/29/2021 at 02:19 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 06/29/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87466
Observation of the Resident
The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above by not documenting observations of residents which poses a potential health and safety risk to persons in care.
POC Due Date: 07/02/2021
Plan of Correction
1
2
3
4
Administrator has agreed to re-train all staff regarding documenting observation of residents on a regular basis and submit staff training sign-in sheet to CCLD by POC date.
Type B
Section Cited
CCR
87405(d)(2)
Administrator - Qualifications and Duties
(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.
(2) Knowledge of and ability to conform to the applicable laws, rules and regulations.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview, the licensee did not comply with the section cited above by not having knowledge of CCLD COVID-19 guidelines/regulations which poses a potential health and safety risk to persons in care.
POC Due Date: 07/02/2021
Plan of Correction
1
2
3
4
Administrator has agreed to review all current CCLD COVID-19 PINs/regulations and submit self-certification 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
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2021


LIC809 (FAS) - (06/04)
Page: 3 of 4