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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005861
Report Date: 08/19/2021
Date Signed: 07/05/2022 10:17:54 AM

Document Has Been Signed on 07/05/2022 10:17 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:GRANDMA'S HOME IIFACILITY NUMBER:
347005861
ADMINISTRATOR:MEHEDINTI, MIHAILFACILITY TYPE:
740
ADDRESS:6520 MILES LANETELEPHONE:
(916) 696-6542
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 4CENSUS: 3DATE:
08/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Administrator, Otilia MehedintiTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Melana Llopis arrived at the facility unannounced on 08/19/2021 for a Required - 1 Year inspection. LPA met with Administrator, Otilia Mehedinti and explained the purpose of the visit.
Prior to 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; 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.

LPA and Administrator toured the facility together. Areas inspected include but are not limited to the following: kitchen, living room, resident bedrooms and bathrooms, backyard, laundry and garage. Facility was odor free and in good condition. LPA observed the fire extinguisher to be last serviced on 5/21/2020 and charged. LPA observed sharps and toxins to be locked and inaccessible to residents in care. LPA found an adequate supply of 7 day nonperishable food items and a 2 day perishable food items. LPA observed resident bedrooms to have sufficient lighting and required furniture. LPA observed bathrooms to have required grab bars and nonskid tile floor surface. LPA toured the backyard and found the outer gate to be unlocked. LPA measured the water temperature at 110 degrees F. Smoke detectors and carbon monoxide devices were tested and were observed to be in working order. LPA found first aid kit to be complete.
LPA reviewed infection control procedures and found facility to be in compliance.

LPA reviewed one (1) resident file and found file to be current and complete. LPA reviewed Administrator(s)' file and found file to be current and complete.

LPA conducted a medication audit for resident (R1) and found there to be no errors.

Exit interview conducted, copy of report provided.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Melana Llopis
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2021
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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