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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800457
Report Date: 07/09/2021
Date Signed: 07/09/2021 11:01:20 AM

Document Has Been Signed on 07/09/2021 11:01 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:GRANADA MANORFACILITY NUMBER:
496800457
ADMINISTRATOR:ILAN, CHEYFACILITY TYPE:
740
ADDRESS:4760 GRANADA DR.TELEPHONE:
(707) 539-7059
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY: 6CENSUS: DATE:
07/09/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator, Chey IlanTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos and Licensing Program Manager (LPM) Kimberley Mota conducted an unannounced case management inspection and met with administrator Chey Ilan. The purpose of this visit is to follow up on an administrative enforcement order issued by the city of Santa Rosa on June 01, 2021 and to inspect property for any title 22 violations. Licensee was in violation of ten city codes. These violations included debris accumulation, non-permitted construction, and exterior rodent harborage/infestation. LPA and LPM began tour at 9:10 AM.

LPA and LPM inspected the facility and observed the following:

Previously damaged ramp has been repaired (Photos taken)
Facility appeared to be free of rodent droppings
Garage refrigerator was stained with blood (Photos taken)
Fire extinguisher was last charged September 23, 2019 (Photos taken)

LPA received current mitigation plan, will approve back at the office.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE: DATE: 07/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/09/2021
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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Document Has Been Signed on 07/09/2021 11:01 AM - It Cannot Be Edited


Created By: Erik Gonzalez Campos On 07/09/2021 at 10:22 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
, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: GRANADA MANOR
FACILITY NUMBER: 496800457

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/09/2021
Section Cited
CCR
87203

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87203 All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by:
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Licensee to have all facility fire extinguishers serviced and charged as performed by a fire extinguisher service company and submit proof of inspection and charge to CCL by the POC date of 7/19/21,
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***Based on LPA observation during the inspection 2 of 2 fire
extinguishers were not currently serviced which poses a potential health and safety risk to the clients in care. LPA observed the last inspection to be 9/23/19.
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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:Kimberley Mota
LICENSING EVALUATOR NAME:Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE:
DATE: 07/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/09/2021


LIC809 (FAS) - (06/04)
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