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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315001899
Report Date: 10/19/2021
Date Signed: 10/19/2021 12:26:07 PM

Document Has Been Signed on 10/19/2021 12:26 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:GRANITE SPRING CARE HOME IIIFACILITY NUMBER:
315001899
ADMINISTRATOR:NATALYA FOKSHAFACILITY TYPE:
740
ADDRESS:1941 FRENSHAM DRIVETELEPHONE:
(916) 952-4192
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY: 6CENSUS: 4DATE:
10/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Tanya Nesteruk- Administrator TIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced on 10/19/2021 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Administrator, Tanya Nesteruk, and explained the purpose of the visit. Prior to initiating the annual 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 contacted licensee 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 Administrator upon entering the facility.

LPA toured the interior and exterior of the facility together with Administrator to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, four (4) resident bedrooms, two (2) bathrooms, kitchen, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Administrator completed the infection control domain and facility was found to be in substantial compliance at this time.

LPA requested for Administrator to submit documents to Community Care Licensing (CCL) due by 10/22/2021.
  • Administrator Certificate
  • Designation of Administrative Responsibility LIC 308
  • Liability Insurance

No deficiencies are being cited as a result of todays inspection.

Exit interview conducted and copy of report left at the facility.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Sarena Keosavang
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2021
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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