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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700862
Report Date: 11/05/2021
Date Signed: 11/05/2021 11:18:20 AM

Document Has Been Signed on 11/05/2021 11:18 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:GRANITE SPRING CARE HOME 4FACILITY NUMBER:
312700862
ADMINISTRATOR:NESTERUK, TATYANAFACILITY TYPE:
740
ADDRESS:6206 GOLDENEYE CT.TELEPHONE:
(916) 879-4405
CITY:ROCKLINSTATE: CAZIP CODE:
95765
CAPACITY: 6CENSUS: 4DATE:
11/05/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Natalie aoksha AdministratorTIME COMPLETED:
11:45 AM
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On November 5, 2021, at 10:10am, Licensing Program Analyst, LPA DeAnna Williams-Lyons arrived unannounced to conduct a required annual inspection. LPA met with Natalie Oaksha , Administrator, and informed her the reason for the visit. Prior to initiating the inspection 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.
LPA completed the inspection tool questionnaire with Natalie with no issues or advisories to report.

LPA observed the following:
This is a 4 bedroom 2.5 bathroom home. Administrator certificate is valid and expires 4/10/2022 . First aid kit fully stocked and ready for emergency use. Fire extinguishers fully charged. Smoke alarms and Carbon Monoxide detector are working Hot water temperature is in the proper range. The facility temperature is 76 degrees F.
Common areas were clean and in good repair. Bedrooms had required furniture and lighting. Facility has the required (2) day perishable supply of food and (7) supply of non-perishable food. Medication was properly stored and locked away. There are no bodies of water on the premises.

To continue see 809-C...
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE: DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2021
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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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: GRANITE SPRING CARE HOME 4
FACILITY NUMBER: 312700862
VISIT DATE: 11/05/2021
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LPA reviewed 1 staff file and 1 resident file. Staff files have all the proper signatures and the facility is conducting training as required. Resident files also had all the required documents with the proper signatures.

As a result of this visit, no deficiencies were cited, per Title 22 Regulations, Division 6.

Administrator shall submit the following documents to update the Regional Office files:
The documents shall be submitted to Community Care Licensing by 12/05/2021:
-LIC 500 facility personnel or staff schedule
-LIC 610 emergency disaster plan
-LIC 308 designation of administrative responsibility
-copy of liability insurance
-updated facility sketch

Exit interview conducted and a copy of this report given to Natalie.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021
LIC809 (FAS) - (06/04)
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