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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005861
Report Date: 03/19/2024
Date Signed: 03/19/2024 10:26:03 AM

Document Has Been Signed on 03/19/2024 10:26 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
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: 2DATE:
03/19/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Mihail MehedintiTIME COMPLETED:
10:30 AM
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On 3/19/24, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit while delivering complaint findings and met with licensee.

On 1/2/24, the department received a complaint regarding R1. While the complaint was unsubstantiated, additional deficiencies were found in the course of the investigation.
In December 2023, statements by licensee and staff showed that S1 was employed for approximately 2 weeks and S2 was employed for 1 day. Department records showed that neither staff was associated to the home through the background checks system.
Furthermore, the licensee did not have personnel files for either S1 of S2.

It was also found that the licensee issued an improper eviction notice to R1’s, responsible party. The issuance of the notice failed to comply with regulation requirements.

As a result of this inspection, the following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.

Report reviewed. Copy of report and appeal rights provided
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE: DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2024
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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Document Has Been Signed on 03/19/2024 10:26 AM - It Cannot Be Edited


Created By: Kevin Mknelly On 03/19/2024 at 09:55 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GRANDMA'S HOME II
FACILITY NUMBER: 347005861

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/27/2024
Section Cited
CCR
87355(e)(2)

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Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as
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Licensee has completed transfer for on enployee. Others are no longer employed.
Licensee will submit a statement of understanding of this requirement by the POC date of 3/27/24
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specified in Section 87355(c)
This requirement was not met based on records and statements the S1 and S2 were not cleared and transferred prior to residing in the home. This posed an immediate risk to residents.
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Type B
03/27/2024
Section Cited
CCR87412(a)

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Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. This requirement was not met based on statements and records review which found personnel files were missing most documents and
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Licensee will submit a statement that S4's personnel file is complete, including training,
by the POC date of 3/27/24
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 proof of training. This posed a potential risk to residents.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Maribeth Senty
LICENSING EVALUATOR NAME:Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:
DATE: 03/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2024


LIC809 (FAS) - (06/04)
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