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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700862
Report Date: 11/08/2022
Date Signed: 11/08/2022 12:30:59 PM

Document Has Been Signed on 11/08/2022 12:30 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 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:
11/08/2022
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME BEGAN:
10:24 AM
MET WITH:Tatyana, Nesteruk, AdministratorTIME COMPLETED:
01:00 PM
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On November 8, 2022 at 10:30am, Licensing Program Analyst (LPA) De Anna Williams-Lyons arrived unannounced to conducted an Annual Inspection, LPA met with administrator Tatyana Nesteruk, who helped LPA with the inspection.

Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of g 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 a N-95 mask was worn for Personal Protective Equipment.

LPA and Tatyana completed the infectious Control questionnaire with no issues or concerns.

The Administrator certificate expires 4/27/2024. The current census is 4. The facilities Administrator’s Certificate, Emergency Disaster Plan, Resident’s Rights and Facility Sketch was available for viewing. The room temperature was 74 degrees F which is within range.

LPA inspected the interior and the exterior of the facility including the common living spaces, the kitchen, resident bedrooms and bathrooms. In the kitchen area, cabinets and drawers were reviewed. Knives and sharp objects were reviewed to make sure that they were locked and made inaccessible to the residents at all times. LPA observed there to be a sufficient amount of 2-day perishable and 7-day non-perishable food. Hot water temperatures were taken and measured at 120 degrees F, which is within the allowed range of 105-120 degrees. There’s appropriate lighting throughout the facility.

To continue see 809-C

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2022
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
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: GRANITE SPRING CARE HOME 4
FACILITY NUMBER: 312700862
VISIT DATE: 11/08/2022
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The facility is a one story home. Living rooms, 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 4 Bedrooms .and 3 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. Hot water temperature is 106 degrees F. The sink, toilet, bathtub and shower operate properly. The facility has a sufficient supply of linens, towels, bedding, etc. for residents in care. 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. First aid kit was present and included the required scissors, tweezers, thermometer and guide. Fire alarms, smoke alarms, and carbon monoxide detectors operate properly. Fire extinguisher is maintained and ready for emergency use. LPA inspected the exterior grounds of this facility. There are no bodies of water on the premises. The perimeter fence, side gates, and latches were in good repair. Passageways are free of obstruction and potential hazards.

Per California Code of Regulations, Title 22, No citations were issued.

The Administrator shall submit updated copies of the LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610D the Emergency Disaster Plan, and copy of current Liability Insurance to update the facility file. Administrator shall submit the listed documents to Licensing no later than December 8, 2022.

An exit interview was conducted and a copy of this report was given to Tatyana..

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

DATE: 11/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2022
LIC809 (FAS) - (06/04)
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