<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800457
Report Date: 11/05/2021
Date Signed: 11/05/2021 01:08:40 PM

Document Has Been Signed on 11/05/2021 01:08 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, 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: 6DATE:
11/05/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Administrator, Chey IlanTIME COMPLETED:
01:20 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced to conduct a Required - 1 Year Inspection at approximately 12:00 PM, and met with administrator Chey Ilan. The inspection was focused on the Infection Control procedures and practices of this facility.

Upon entry administrator asked LPA to sign-in on visitor sheet. Administrator took LPA's temperature. At primary entrance LPA observed visitor logs. LPA conducted walk through of the facility with administrator and observed COVID postings throughout. Facility was a comfortable temperature and exits were free from obstructions. Mitigation plan has been submitted and reviewed by Community Care Licensing (CCL).

Hand sanitizer is kept throughout the facility. Per administrator, updated infection control guidelines and PINs are communicated to responsible parties when they visit. Staff have not completed Personal Protective Equipment (PPE)/infection control training nor been N95 fit tested. LPA provided guidance to contact local public health for training resources. High touch surface areas are disinfected daily. Facility has three shared bedrooms but a space is available to isolate a resident if necessary. LPA provided guidance to contact CCL regional office for more PPE. Visitation is allowed inside but there is also a designated space outdoors for visitation.

Residents' emergency contact information has been updated and administrator confirmed staff are familiar with 911 procedures and protocols. Toxins are secured and inaccessible in locked hallway closet at the back of the facility. Medications are centrally stored in a locked cabinet making them inaccessible to residents.

LPA requested updated copy of the facility's liability insurance.

No deficiencies cited during today's inspection.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE: DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1