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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700852
Report Date: 08/17/2022
Date Signed: 08/17/2022 10:20:15 AM

Document Has Been Signed on 08/17/2022 10:20 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:LAKESIDE SENIOR LIVING OF GRANITE BAY, LLCFACILITY NUMBER:
312700852
ADMINISTRATOR:LORDACHE-STIR, ADRIANAFACILITY TYPE:
740
ADDRESS:8365 BARTON RDTELEPHONE:
(916) 205-2273
CITY:GRANITE BAYSTATE: CAZIP CODE:
95746
CAPACITY: 6CENSUS: 6DATE:
08/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:22 AM
MET WITH:Adriana Lordache-Stir, LicenseeTIME COMPLETED:
10:38 AM
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On August 17, 2022, at 8:30am, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived to conduct a 1 year required annual inspection. LPA met with the licensee, Adriana Lordoache-Stir, and explained the reason for the visit. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms, and completed a facility risk assessment. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: mask. Additionally, LPA was screened by the staff upon arrival. Currently, the facility has 6 residents residing in the home. The home was 76 degrees F.
LPA and Adriana completed the Infectious Control Questionnaire with no issues or concerns to report.

LPA Observations:.

LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, and kitchen. LPA observed there to be a sufficient amount of 2-day perishable and 7-day non-perishable food. There’s appropriate lighting throughout the facility.

First aid kit was present and complete. Fire extinguisher is maintained and ready for emergency use. The sink, toilet, bathtub and shower operate properly. Washer and dryer was present and operating properly. Toxic substances, laundry and cleaning supplies are inaccessible. There’s a centralized storage area for resident’s medication. Medication cabinet was locked. The facility Medication Administration Record was reviewed as well as the dispensing log and was complete and current.

To continue see 809-C...

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE: DATE: 08/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/17/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: LAKESIDE SENIOR LIVING OF GRANITE BAY, LLC
FACILITY NUMBER: 312700852
VISIT DATE: 08/17/2022
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Living room, dining room, and areas designated for resident use were toured. Furniture and furnishings were observed to be sufficient and in good repair. Resident bedrooms and bathrooms were toured. There are 5 Bedrooms and 2 bathrooms for residents. All rooms had the required items of furniture. Window screens were on and in good repair. Bathrooms were clean, sanitary and odorless and consisted of grab bars and non-skid mats.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations were observed during this visit.

The administrator shall submit updated copies of the LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610E the Emergency Disaster Plan, and copy of your current Liability Insurance to update the facility file in our Regional Office. Administrator shall submit the listed documents to Licensing no later than September 17, 2022.

Exit interview conducted and a copy of this report was given.

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2022
LIC809 (FAS) - (06/04)
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