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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800457
Report Date: 11/18/2024
Date Signed: 11/18/2024 05:55:42 PM

Document Has Been Signed on 11/18/2024 05:55 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/
DIRECTOR:		ILAN, CHEYFACILITY TYPE:
740
ADDRESS:4760 GRANADA DR.TELEPHONE:
(707) 539-7059
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY: 6CENSUS: 6DATE:
11/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:10 PM
MET WITH:Clayton Anderson, licenseeTIME VISIT/
INSPECTION COMPLETED:
06:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by Licensee Clayton Anderson.

LPA and licensee toured the building and grounds. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered. Freezer located in the garage needs to be cleaned out and all expired items removed. Kitchen cabinet containing cleaning supplies was locked. Kitchen drawer with sharp knives locked.

All bedrooms were equipped with lighting, night stand, and chest of drawers. Dead insects found in the window sill of rooms #1 and #2. Resident bathroom had required bath mat and grab bar. Water temperature in sink accessible to residents in care measured at 109.3 and 112.5 degrees F which is within the allowable range of 105 to 120 degrees F.

Upon LPA arrival to facility, passageway was blocked due to multiple walkers being present (deficiency cited, see 809D). LPA discussed with licensee providing activities for the residents that meet regulation. Currently, the facility does not offer an activity program that addresses the needs and limitations of residents with dementia which include large motor activities and perceptual and sensory stimulation (deficiency cited, see 809D). Additionally, LPA and licensee discussed activities and providing room enough in the facility for activities and visitation. There are six [6] residents and [4] possible seats to sit in. The only indoor area accessible to residents for activities and for recreation is the small dining area occupied by dining table with chairs, one small love seat, and 3 recliners. LPA discussed with licensee providing sufficient space for residents to use for activities and leisure. The facility's Living room is currently occupied by licensee's alleged non-resident client and being used as a bedroom. LPA and licensee discussed making living room accessible to residents in order to maintain compliance with regulation (deficiency cited, see 809D).

Continued on 809C...
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: 11/18/2024
NARRATIVE
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Continued from 809...

Fire extinguishers were last inspected 8/27/24. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Facility’s last quarterly disaster drills were conducted 10/30/2024. Emergency fire exit path on right facing side of the facility is blocked by multiple items (deficiency cited, see 809D). Ramp on deck leading to grass has a soft spot and is broken/worn through. Tree House and ladder on tree in backyard is not secured, must be made inaccessible to residents (deficiency cited, see 809D).



LPA conducted a review of six [6] resident records. R1 and R2 do not have current appraisals (deficiency cited, see 809D). LPA conducted review of five [5] staff records. S1, S2 did not have current 1st Aid/CPR (deficiency cited, see 809D). LPA reviewed training materials used for staff training. Medications training is conducted using a manual from 2001 and other topics on burned CD discs dated 2015. Licensee to either use an approved vendor for training or submit updated training materials to CCL for approval no later than 12/2/2024.

LPA conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet.

Chey Ilan Administrator Certificate 7005493740 has expired but renewal is pending as of 5/3/2024.



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
Liability Insurance

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Licensee. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with licensee and a copy of this report was given.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2024
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Document Has Been Signed on 11/18/2024 05:55 PM - It Cannot Be Edited


Created By: Christi Coppo On 11/18/2024 at 05:04 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: 11/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on LPA observation, the licensee did not comply with the section cited above in that Emergency fire exit path on right facing side of the facility is blocked by multiple items and obstructed, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/19/2024
Plan of Correction
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2
3
4
Facility to submit photos of cleared emergency fire exit path on right facing side of the facility by plan of correction due date.
Type A
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on LPA observation, the licensee did not comply with the section cited above in that ramp on deck leading to grass has a soft spot and is broken/worn through, tree house and ladder on tree in backyard is not secured, must be made inaccessible to residents, dead insects found in the window sills of bedrooms #1 and #2, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/19/2024
Plan of Correction
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Facility to submit plan to make tree house inaccessible to residents, ramp repaired, and dead insects removed from window sills. Facility to submit photo of window sills that are free of insects by plan of correction due date. Tree house inaccessible to residents must be completed no later than 11/25/24. Deck ramp must be repaired no later than 12/2/24
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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2024


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Document Has Been Signed on 11/18/2024 05:55 PM - It Cannot Be Edited


Created By: Christi Coppo On 11/18/2024 at 05:04 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: 11/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on LPA observation, the licensee did not comply with the section cited above in that passageways were blocked due to walkers present and blocking, poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/19/2024
Plan of Correction
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Facility to submit LIC9098 self-certifying that passageways will remain free from obstruction by plan of correction due date.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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4
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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2024


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Document Has Been Signed on 11/18/2024 05:55 PM - It Cannot Be Edited


Created By: Christi Coppo On 11/18/2024 at 05:04 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: 11/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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4
Based on LPA observation and record review, the licensee did not comply with the section cited above in that S1 and S2 did not have current 1st Aid/CPR certification, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/02/2024
Plan of Correction
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Facility to submit to CCL current 1st Aid/CPR certification for S1 and S2 by plan of correction due date.
Type B
Section Cited
CCR
87219(h)
Planned Activities
(h) Facilities shall provide sufficient space to accommodate both indoor and outdoor activities. Activities shall be encouraged by provision of:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in that the only indoor area accessible to residents for activiies and for recreation does not provide sufficientt space for residents to use for activities and leisure, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/25/2024
Plan of Correction
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Facility to submit plan to CCL for approval of how they will make the facility living room accessible to residents to use for visititaion, activities, and lesiure by plan of correction due date. If plan is approved, implementaion of plan to be completed no later than 12/9/2024.
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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2024


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 11/18/2024 05:55 PM - It Cannot Be Edited


Created By: Christi Coppo On 11/18/2024 at 05:04 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: 11/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(c)
Reappraisals
(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on LPA observation, the licensee did not comply with the section cited above in R1 and R2 did not have current appraisal, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/25/2024
Plan of Correction
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Facility to submit to CCL current appraisal signed by all parties for R1 and R2 by plan of correction due date.
Type B
Section Cited
CCR
87705(c)(7)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (7) An activity program shall address the needs and limitations of residents with dementia and include large motor activities and perceptual and sensory stimulation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on LPA observation, the licensee did not comply with the section cited above in that activities are not provided in compliance with regulation, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/25/2024
Plan of Correction
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2
3
4
Facility to submit activity program that meets the above regulation requirements to CCL by plan of correction due date. The program shall address specific activities that address the needs and limitations of residents with dementia and include large motor activities and perceptual and sensory stimulation. The plan for the program to be sumitted to CCL for approval by plan of correction due date.
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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2024


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