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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881620
Report Date: 06/18/2025
Date Signed: 06/18/2025 11:19:43 AM

Document Has Been Signed on 06/18/2025 11:19 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:GRANITE SENIOR LIVINGFACILITY NUMBER:
331881620
ADMINISTRATOR/
DIRECTOR:		UY, MARLON FREDERICKFACILITY TYPE:
740
ADDRESS:1262 GRANITE DRTELEPHONE:
(951) 260-3243
CITY:HEMETSTATE: CAZIP CODE:
92543
CAPACITY: 6CENSUS: 0DATE:
06/18/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Mark Delon, ApplicantTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On 06/18/2025, Licensing Program Analyst (LPA) Debbie Palacios conducted an announced visit to complete the Pre-licensing inspection. LPA met with applicant Mark Delon and LPA was granted entry to the facility. The facility was approved to serve elderly of ages 60 and over, for six (6) ambulatory residents, of which four (4) may be non-ambulatory in rooms two (2) and three (3). Waiver/granted for hospice care for six (6).

The facility has three (3) bedrooms, two (2) bathrooms, kitchen/dining area, living room area, backyard and an attach garage. LPA toured the interior and exterior areas of the facility. The following were inspected:

LPA observed resident bedrooms with the required bedding and furniture, such as, clean mattresses/linen, nightstands, dressers, chairs, and lighting. Resident bathrooms had clean appliances that were operating in safe and sanitary condition and the showers contained non-slip mats and grab bars.

LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods. The knives and sharp objects were locked in kitchen cabinet. The facility contains PPE equipment and hand washing supplies locked in the hallway closet.

The washer and dryer are located in the laundry room and has a locked cabinet for the chemicals and detergents. Resident files, staff files, and medication will be located in a locked closet located in the hallway. The facility maintains an adequate supply of clean linen and personal hygiene supply.
NAME OF LICENSING PROGRAM MANAGER: Rikesha Stamps
NAME OF LICENSING PROGRAM ANALYST: Debbie Palacios
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/18/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: GRANITE SENIOR LIVING
FACILITY NUMBER: 331881620
VISIT DATE: 06/18/2025
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The facility does not have any bodies of water on the property. There is a covered area with seating for the all the residents. All passageways were free from obstruction. LPA observed two (2) charged fire extinguishers in the facility last serviced 11/23/2024. The smoke detectors and carbon monoxide alarms were operational.

LPA observed required postings including emergency/disaster plans, LTCO poster, and personal rights. LPA observed an adequate amount of activities present in the living room cabinet. LPA observed first aid kit with the required items and manual.



LPA observed that the physical plant is clean, in good repair, and to be hazard-free during today’s visit. LPA have determined that the facility meets the operational requirements for licensure. The Pre-licensing inspection is complete, and this facility has no deficiencies. The facility has satisfied all requirements in accordance with Title 22, California Code of Regulations.

An exit interview was conducted, and this report was discussed and provided to applicant Mark Delon.
NAME OF LICENSING PROGRAM MANAGER: Rikesha Stamps
NAME OF LICENSING PROGRAM ANALYST: Debbie Palacios
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2025
LIC809 (FAS) - (06/04)
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