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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800457
Report Date: 11/24/2025
Date Signed: 11/24/2025 03:15:51 PM

Document Has Been Signed on 11/24/2025 03:15 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: 5DATE:
11/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:35 AM
MET WITH:Clayton Anderson, LicenseeTIME VISIT/
INSPECTION COMPLETED:
03:25 PM
NARRATIVE
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At approximately 8:35 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a Required 1 Year visit. Administrator Chey Ilan was not at the facility during the inspection. Granada Manor is Licensed as a Residential Care Facility for the Elderly (RCFE). The facility is a single story ranch house. The facility has an approved fire clearance for six (6) non-ambulatory residents. Upon arrival, LPA was informed that there were five (5) residents in care and one (1) staff member on-site. At approximately 8:50 AM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation.
At approximately 9:00 AM, LPA toured the facility. All exits were clear and unobstructed. The facility's two (2) fire extinguishers were last serviced and tagged on 8/21/2025. The facility was sufficiently lighted. LPA inspected three (3) resident bedrooms and found all to have sufficient lighting and furnishings as required per Title 22 Regulations. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. LPA observed that there were multiple canned and dried food products in the pantry closet that have expired. This deficiency will be cited. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. In the front living room LPA observed multiple prescription and over the counter (OTC) medications that were unsecured. This deficiency will be cited. Additionally, there were unsecured toxins in the front living room. This deficiency will be cited. Facility has an infection control plan as required. The facility has a required emergency disaster plan. The facility is conducting fire and emergency drills quarterly. The last disaster drill was conducted in 8/2025. The facility does have emergency food and supplies to meet the "72 hour shelter in place" requirements. Hot water temperatures for all sinks in facility were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. Facility smoke detectors and carbon monoxide detectors were tested and observed to be operational. Continued on 809-C...
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Robert Frank
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/24/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 11/24/2025
NARRATIVE
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...Continued from 809
Next to the front living room is a staff room. This room contained toxins and the room is not being locked which leaves the toxins accessible to residents. This deficiency will the cited. Within the garage there is one (1) staff bedroom as noted on the facility drawings that was approved by the Santa Rosa Fire Department during their inspection on 7/2/2020. During today's inspection LPA observed that this one (1) bedroom has been split into two (2) separate rooms. The added room (in the far corner of the garage) was observed to contain computers and servers with unsecured data and power cables strung across the ceiling and floors. The Licensee has not submitted updated facility drawings showing this added room to Community Care Licensing (CCL) so that CCL can request the Santa Rosa Fire Department to inspected the added room. This deficiency will be cited.

At approximately 10:50 AM, LPA reviewed five (5) resident files. Five (5) of five (5) resident files were observed with all required documentation. LPA reviewed five (5) staff files. Three (3) of five (5) staff files (for staff members S1,S2 & S3) were observed not have documentation of annual training for the current year. This deficiency will be cited. Two (2) of five (5) staff files were observed with all required documentation including First Aid and CPR certification and proper training documentation. LPA spot checked Medication for two (2) residents. LPA observed all medications to be centrally stored, secure and with proper documentation. The facility does not handle resident’s monies for personal and incidental items.

Chey Illan’s Administrator Certification 7005493740 is current with an expiration date of 8/7/2026.

LPA requested the following documents be submitted to Community Care Licensing by 12/23/2025:


LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Proof of Liability Insurance

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, LIC-809Ds, Plan of Corrections, 811 Confidential Names and Appeal Rights discussed and provided to Licensee Anderson. Signature on form confirms receipt of documents.
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Robert Frank
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/24/2025 03:15 PM - It Cannot Be Edited


Created By: Robert Frank On 11/24/2025 at 02:13 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: 11/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that multiple prescription medications were unsecured in the front living room area which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/25/2025
Plan of Correction
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Licensee or Administrator will submit an LIC 9098 Self certifying that all medications in the facility will be kept secured in the future to Community Care Licensing (CCL) by the POC due date of 11/25/2025. Additionally, Licensee or administrator will submit proof of all staff having taken medication management training to CCL by 12/15/2025.
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.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Robert Frank
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/24/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/24/2025 03:15 PM - It Cannot Be Edited


Created By: Robert Frank On 11/24/2025 at 02:13 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: 11/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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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Based on observation & record review, the licensee did not comply with the section cited above in that the licensee did not submit an updated LIC 999 Facility Sketch showing two (2) separate rooms in the garage to Community Care Licensing (CCL) so that a Fire Inspection can be scheduled to approve the added room which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/15/2025
Plan of Correction
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Licensee or Administrator to submit an update LIC 999 Facility sketch showing two (2) separate rooms in the garage to Community Care Licensing (CCL) so that a Fire Inspection can be scheduled to approve the added room by POC due date of 12/15/2025.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation & record review, the licensee did not comply with the section cited above in that three (3) of five (5) staff members (S1, S2 & S3) did not have proof of current year annual training in their personal files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/15/2025
Plan of Correction
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Licensee or Administrator to submit proof that staff members S1, S2 and S3 have begun their annual training to Community Care Licensing by POC due date of 12/15/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Robert Frank
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/24/2025


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 11/24/2025 03:15 PM - It Cannot Be Edited


Created By: Robert Frank On 11/24/2025 at 02:13 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: 11/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that multiple canned and dry food products in the pantry had passed their expiration dates which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/15/2025
Plan of Correction
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Licensee or Administrator will submit an LIC 9098 Proof of Correction self certifying that all expired food products in the facility have been disposed to Community Care Licensing by POC due date of 12/15/2025.
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.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Robert Frank
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/24/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/24/2025 03:15 PM - It Cannot Be Edited


Created By: Robert Frank On 11/24/2025 at 02:41 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: 11/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that unsecured toxins were observed in the front living room and the staff room next to the front living room which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/15/2025
Plan of Correction
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Licensee or Administrator will submit an LIC 9098 Proof of Correction self certifying that all toxins in the facility have been secured. Additionally, the licensee will send a photograph of lock added to door of staff room if toxins are not removed from that room. All items to be submitted to Community Care Licensing by the POC due date of 12/15/2025.
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.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Robert Frank
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/24/2025


LIC809 (FAS) - (06/04)
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