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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602371
Report Date: 08/04/2022
Date Signed: 08/04/2022 11:10:38 AM

Document Has Been Signed on 08/04/2022 11:10 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, 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: 6DATE:
08/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Amanda Palomino, licenseeTIME COMPLETED:
11:25 AM
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Licensing Program Analyst (LPA) Cynthia Chan conducted the required annual inspection with the focus of the Infection Control domain. LPA met with licensee Amanda Palomino and Administrator Boris Palomino to explain the reason for the visit. The facility is licensed for 6 non-ambulatory residents age 60 and over. The hospice waiver is approved for 4.

LPA toured the facility inside and out and observed the following:
* There are 4 bedrooms, 3 bathrooms, living room, dining room, kitchen, and detached garage. There are no pools or bodies of water. The facility is well maintained and clean.
* The bedrooms contain the required furnishing and the beds are moved at least 6 feet apart for shared rooms.
* Staff are taking the temperature of all residents, staff, and visitors.
* COVID-19 signage are posted throughout the facility. Handwashing signs are posted in the bathrooms.
* Sufficient food supplies of 2 day perishable and a week of nonperishable are observed.
* Adequate supplies of PPE are stored in the garage.
* Knives and sharps are stored and locked in a kitchen cabinet.
* Cleaning products and chemicals are locked in the laundry area.
* Staff and visitors were wearing face masks.
* Medications were reviewed for all 6 residents and there are no discrepancies noted.
* Emergency numbers are updated and posted for staff use.

Per the licensee, they are continuing to follow their mitigation plan. They have backup staffing if needed.

There are no deficiencies issued. an exit interview was conducted and a copy of this report was given.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2022
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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