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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800457
Report Date: 11/07/2023
Date Signed: 11/07/2023 01:38:18 PM

Document Has Been Signed on 11/07/2023 01:38 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
SANTA ROSA RO, 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:
11/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:33 AM
MET WITH:Clayton Anderson, OwnerTIME COMPLETED:
01:51 PM
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At approximately 8:33am Licensing Program Analyst (LPA) Christi Coppo and arrived unannounced to conduct a required Annual inspection and was greeted by Chey Ivan, Administrator and Clayton Anderson, Licensee. Facility currently has 5 residents. Facility contact information was reviewed.

At approximately 9:00am LPA and Licensee toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA and Licensee observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Celery and other vegetable bag was browning and not edible. Licensee threw the browning bags of celery and vegetable away immediately. One head of cabbage had black spots and patches. Licensee threw cabbage away immediately. Food was found to be stored in a safe manner with open items covered and labeled. Kitchen cabinet containing cleaning supplies was locked.

All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Resident bathrooms had required bath mats and grab bars. Water temperature in sink(s) accessible to residents in care measured at 116.1 F and 106.2 F degrees which is within the allowable range of 105 to 120 degrees F.

Fire extinguishers were last inspected August 1, 2023. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Exit doors and sliding doors have an auditory alert system that was functional at time of inspection. Facility conducts quarterly disaster drills. Facility has a backup generator for use during a power outage.

At approximately 11:15am LPA and Administrator conducted a review of 5 resident records and 1 staff record. Residents R1, R2, and R3 all have diagnosis of dementia but their LIC602 Medical Assessments were all not current as required per Title 22 regulation 87705(5).

Report continued on LIC 809-C

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 11/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: GRANADA MANOR
FACILITY NUMBER: 496800457
VISIT DATE: 11/07/2023
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Report continued from LIC 809....

At approximately 12:50pm LPA and Administrator conducted a spot check of medication and medication records. Medication is centrally stored in a 2 locked cabinets in the kitchen area.

Chey Ilan Administrator Certificate 6018531740 expires 08/07/2024. All fees are current as of this time. Fee renewal due January 2024. LIS pin printed and given to Licensee.

LPA and Licensee discussed facility's Infection Control Plan and Emergency Disaster Plan. Licensee verified no updates needed.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC500- Personnel Report
LIC308- Designation of Responsibility
Copy of Deed or Mortgage

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

Exit interview conducted with Administrator and a copy of this report was given

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/07/2023 01:38 PM - It Cannot Be Edited


Created By: Christi Coppo On 11/07/2023 at 12:22 PM
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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: GRANADA MANOR
FACILITY NUMBER: 496800457

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(5)
87705 Care of Persons with Dementia 5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.

This requirement is not met as evidenced by: R1, R2, and R3 all have dementia diagnosis but their LIC602 are not current within 12 months
Deficient Practice Statement
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Based on LPA and Administrator record review, the licensee did not comply with the section cited above in [3] out of [5] resident records with a diagnosis of dementia, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/28/2023
Plan of Correction
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Adminsitrator agrees to request each resident, with a diagnosis of dementia, have a current LIC602 updated/brought current by POC due date of 11/28/2023.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Bethany Moellers
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2023


LIC809 (FAS) - (06/04)
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