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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700996
Report Date: 10/26/2021
Date Signed: 10/26/2021 12:20:42 PM

Document Has Been Signed on 10/26/2021 12:20 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:WELLQUEST GRANITE BAY TENANTCO LLCFACILITY NUMBER:
312700996
ADMINISTRATOR:MANOMHEHRI, PARIFACILITY TYPE:
740
ADDRESS:9747 SIERRA COLLEGE BLVDTELEPHONE:
(916) 864-9800
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY: 135CENSUS: 77DATE:
10/26/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH: Business Director Jessica Galvez and Deziree Thitphaneth- Health and Wellness Director TIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced on 10/26/2021 to conduct a Case Management visit. LPA met with Business Director Jessica Galvez and Health and Wellness Director Deziree Thitphaneth, and explained the purpose of the visit. Prior to initiating the Case Management 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 contacted Business Director and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA were screened by facility staff upon entering the facility.

On 10/18/2021, the Department received an Unusual Incident/Injury report stating resident (R1) had an unwitnessed fall that occurred on 10/17/2021 at approximately 6 PM. R1 was found laying on the floor in the living room of R1's apartment. R1 had lost balance while ambulating and fell. R1 was noted with bloody nose and pain to right rib. 911 was called and R1 was transferred to ER. On 10/17/2021, R1 returned to the community with no new orders. R1 was diagnosed with fracture of the nasal bone.

LPA Keosavang requested for a copy of R1's Physician's Report and discharge medical records for review.

No deficiencies are being cited.

An exit interview was conducted with Business Director, Jessica Galvez, and a copy of this report will be provided to the facility via email.

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Sarena Keosavang
LICENSING EVALUATOR SIGNATURE: DATE: 10/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/26/2021
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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