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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700852
Report Date: 08/23/2023
Date Signed: 08/23/2023 09:35:38 AM

Document Has Been Signed on 08/23/2023 09:35 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
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
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: 5DATE:
08/23/2023
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Elle Martin, CaregiverTIME COMPLETED:
09:40 AM
NARRATIVE
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct a collateral visit. LPA met with caregiver during today's visit and they informed administrator of LPA's visit.

LPA arrived today to interview a resident concerning an issue that was not related to this facility.

In the areas that were evaluated, no deficiencies were observed at the time of the visit.

Exit Interview conducted.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2023
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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