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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800457
Report Date: 11/18/2022
Date Signed: 11/18/2022 03:25:07 PM

Document Has Been Signed on 11/18/2022 03:25 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
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: 5DATE:
11/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Administrator, Chey IlanTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 11/18/2022 to conduct a Required - 1 Year inspection. LPA met with administrator, Chey Ilan and licensee, Clayton Anderson. This inspection is focused on the infection control practices and procedures of this facility.

LPA toured facility with administrator. Facility has 3 shared bedrooms. Building and grounds were clean and in good repair. Exits and walkways were clear from obstructions. Facility is renovating deck and is currently not available for resident use. Santa Rosa Fire department performed an inspection of the facility on 11/14/2022. Fire extinguishers were charged and current. Carbon monoxide and smoke detectors were present and operational throughout the facility. Facility is currently conducting screening of visitors at the front entrance. LPA observed sufficient perishable and non-perishable food in the kitchen. Toxins were secured and inaccessible to residents in care. Medications were locked and inaccessible to residents in care. LPA and administrator discussed resident record keeping, including but not limited to LIC 602s, initial appraisals, reassessments, needs/services plans, and medication lists. LPA provided list of training required for staff annually. LPA and administrator discussed CPR/First Aid requirements.

LPA is requesting the following documents be submitted to Community Care Licensing within 30 days of today's inspection:

LIC 500 Personnel Report
LIC 9020 Resident Roster
LIC 308 Designation of Facility Responsibility
LIC 610 Emergency Disaster Plan
Evidence of Liability Insurance

No deficiencies cited during today's inspection. Exit interview conducted with administrator.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2022
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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