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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315001899
Report Date: 08/11/2022
Date Signed: 08/11/2022 01:00:18 PM

Document Has Been Signed on 08/11/2022 01:00 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: DATE:
08/11/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:40 AM
MET WITH:Natalya Foksha, AdministratorTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Michael Hood met with Licensee, Natalya Foksha, to conduct an inspection.

During inspection, LPA observed a staff member not wearing a mask while on the premises. LPA also observed staff not screening visitors upon entry of facility. LPA provided technical assistance regarding staff not wearing a mask and screening visitors. Staff member put on mask after technical assistance.

Exit interview was conducted with Licensee. A copy of this report was provided. The Licensee’s signature on this form acknowledges receipt of these documents.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE: DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/11/2022
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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