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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602371
Report Date: 10/19/2021
Date Signed: 10/19/2021 04:14:44 PM

Document Has Been Signed on 10/19/2021 04:14 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:GRANDRIDGE RESIDENTIAL CAREFACILITY NUMBER:
198602371
ADMINISTRATOR:PALOMINO, BORISFACILITY TYPE:
740
ADDRESS:2016 S GRANDRIDGE AVETELEPHONE:
(323) 353-1167
CITY:MONTEREY PARKSTATE: CAZIP CODE:
91754
CAPACITY: 6CENSUS: 5DATE:
10/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Boris Palomino, AdministratorTIME COMPLETED:
04:25 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted the required annual inspection with the focus of the inspection control domain. LPA arrived unannounced and Staff, Sarah Aguirre who allowed entry. Administrator, Boris Palomino, arrived shortly thereafter to assist with the visit. The facility is approved for 6 non-ambulatory residents, ages 60 and over. There is a hospice waiver approved for 4 residents.

This facility has 4 bedrooms for residents and 1 bedroom designated for a live-in staff, 3 bathrooms, living room, kitchen, laundry room, and dining area. There are no bodies of water at the facility.

LPA toured the facility inside and out with the Administrator. LPA observed the following:
* Upon entry, temperature was taken and logged. Staff and Residents' temperature are taken and documented daily.
* There is one entry point for all visitors.
* Covid-19 signage are posted around the facility and in the bathrooms.
* Staff were wearing face coverings.
* Food supplies were adequate.
* Bathrooms are stocked with soap and paper towels.
* Extra PPE supplies are stored in the garage.
* Knives, disinfectants, and cleaning solutions are locked.
* Medications were reviewed for all 5 residents and are being administered as prescribed by the physician.
* Residents' files have updated emergency contact information.
* No staff files were reviewed today.

There were no deficiencies observed during the visit today. An exit interview was conducted and the report along with appeal rights were given to the Administrator.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2021
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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