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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700852
Report Date: 07/02/2024
Date Signed: 07/02/2024 11:37:20 AM

Document Has Been Signed on 07/02/2024 11:37 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:LAKESIDE SENIOR LIVING OF GRANITE BAY, LLCFACILITY NUMBER:
312700852
ADMINISTRATOR/
DIRECTOR:		LORDACHE-STIR, ADRIANAFACILITY TYPE:
740
ADDRESS:8365 BARTON RDTELEPHONE:
(916) 205-2273
CITY:GRANITE BAYSTATE: CAZIP CODE:
95746
CAPACITY: 6CENSUS: 6DATE:
07/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Sheree Hall Thompson, staffTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Melissa Parks arrived on Tuesday July 2, 2024 to conduct the unannounced annual inspection.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA Parks reviewed resident (6) and staff files (3). All resident files contained the required paperwork. Staff files contained the required paperwork and training.

LPA Parks and staff Sheree toured the facility together to ensure the health and safety of residents in care. The areas toured included resident rooms, bathrooms, living room, kitchen, and garage. In the areas toured, there were no health or safety violations observed.

Facility was clean and well organized. All required posting were observed. All knives/sharps are kept locked and inaccessible to residents.

No deficiencies cited. Exit interview conducted. A copy of this report was emailed to the facility.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Melissa Parks
LICENSING EVALUATOR SIGNATURE: DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/02/2024
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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