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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800457
Report Date: 12/19/2024
Date Signed: 12/19/2024 02:03:39 PM

Document Has Been Signed on 12/19/2024 02:03 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: DATE:
12/19/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:33 PM
MET WITH:Licensee, Clayton AndersonTIME VISIT/
INSPECTION COMPLETED:
02:18 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a plan of correction visit and was greeted by Licensee Clayton Anderson.

On 11/18/24 during the required annual inspection, 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 of regulation 87219(h) was cited on a 809D with the following plan of correction: Facility to submit plan to CCL for approval of how they will make the facility living room accessible to residents to use for visitation, activities, and leisure by plan of correction due date. If plan is approved, implementation of plan to be completed no later than 12/9/2024. Plan received on 11/26/24.

Upon arrival today, 12/19/24 LPA observed the door to the space that is supposed to be a living room to be closed. When LPA opened the door, the alleged non-resident client was present eating a meal in the recliner. The room had not been cleared of the alleged non-resident client belongings or bed. LPA asked licensee why the room had not been cleared out and made for resident use like the plan of correction required be done by 12/9/24. Licensee claims that they were waiting on the LPA to officially approve the plan. LPA did approve the plan submitted to CCL on 11/26/24, but LPA could not produce email with approval. Therefore, one week is being granted to the licensee so that they may fulfill the plan of correction.

As of today, LPA has officially approved the plan to move the alleged non-resident client to the designated staff room identified as staff room on the facility sketch, so that the full living room will be fully available to residents and the door to living room removed. The full living room to be fully available to residents, with the door to living room removed, no later than 12/26/24.


Continued on 809C...
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2024
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: 12/19/2024
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Continued on 809...

LPA will return to facility to conduct a subsequent plan of correction visit to verify the full living room is fully available to residents and the door to living room was removed.

Additionally, licensee claimed space on the other side of the bookshelves in the living room is used as a COVID sick room for residents. LPA advised a COVID sick room is not required per regulation. LPA also clarified with licensee that the area in the living room blocked off by bookshelves is not a sick room, it is part of the living room; it is a designed sleeping area that may not be used. LPA advised licensee will need to come to the Santa Rosa regional office to have a meeting to discuss areas of concern. Date of office meeting will be determined and LPA will notify licensee of date of office meeting.

No deficiencies cited. Exit interview conducted with licensee and copy of report given.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024
LIC809 (FAS) - (06/04)
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