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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804250
Report Date: 08/05/2025
Date Signed: 08/05/2025 04:15:35 PM

Document Has Been Signed on 08/05/2025 04:15 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:GRAND CRU SENIOR CARE CORPFACILITY NUMBER:
496804250
ADMINISTRATOR/
DIRECTOR:		SEKHON, TEJPALFACILITY TYPE:
740
ADDRESS:2540 SUMMERFIELD RDTELEPHONE:
(707) 843-5629
CITY:SANTA ROSASTATE: CAZIP CODE:
95405
CAPACITY: 6CENSUS: 6DATE:
08/05/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Tejpal Sekhon, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:29 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by caregiver. Administrator Tejpal Sekhon arrived later. Facility staff roster information was reviewed.

At approximately 9:30am LPA toured the building and grounds. The facility was found to be at a comfortable temperature. 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. Kitchen drawer with sharp knives locked. LPA observed flooring in kitchen to have small cracks/spaces that do not present as a tripping hazard, yet, but LPA discussed with Admin replacing the floor planks so that they do not present as a tripping hazard in the near future. Floor planks in back of facility by rooms #5 and #6 also have small cracks/spaces; per Admin the flooring in the entire facility is scheduled to be replaced/addressed within the year.

While conducting physical plant inspection, LPA observed only one caregiver present at facility. However, LPA observed three residents needing care at the same time. Resident (R1) attempted to get up by themselves to go to the bathroom but started to fall, as they cannot walk properly on their right foot and also having an extremely hard time establishing balance with their walker. Caregiver was down the hall in room #4 assisting resident (R2) with incontinence care. Caregiver had to leave R2 to attend to R1, leaving R2 in their bed. Caregiver assisted R1 on to the toilet, but then had to leave them in order to go back to room #4 and resume attending to R1. While all this was taking place, resident (R3) was in the kitchen requesting help to get out of the recliner chair, as they needed to use the restroom, but caregiver was busy alternating between R1 and R2 such that they could not attend to

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NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/05/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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.

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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: GRAND CRU SENIOR CARE CORP
FACILITY NUMBER: 496804250
VISIT DATE: 08/05/2025
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meeting R3's care needs. LPA discussed staffing with Admin and advised that at all times staff must be sufficient in quantity and qualification such that they are able to meet the care needs of all residents. Admin advised LPA that if he must staff 2 people on each shift, that his staffing overhead would be raised such that it would cause hardship. Additionally, Admin is concerned about staff redundancy. LPA discussed providing residents with activities and outdoor supervision/assistance which would eliminate any redundancy. Throughout visit Admin and LPA continuously discussed staffing ratios.

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 bathroom had required bath mat and grab bar. Water temperature in sink accessible to residents in care measured at 111.3 degrees F in the kitchen, 109 degrees F in room #102.1, and 110 degrees F in the main hall bathroom which are all within the allowable range of 105 to 120 degrees F. LPA observed feces soiled brief in half bath across from rooms #5 and #6 in a trash can without a lid. Additionally, LPA observed urine soiled brief and used chucks in main bath garbage can which also did not have a lid (deficiency cited, see 809D).

LPA unable to determine when fire extinguishers were last inspected as there are no service tags present. However, all fire extinguishers are showing as charged. LPA and Admin discussed having fire extinguishers inspected annually. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Facility’s last quarterly disaster drills were conducted 4/5/25. LPA advised to be sure to do drills quarterly.

At approximately 11:00am LPA conducted a review of six [6] resident records. LPA discussed updating Admission Agreements from old facility and making current using current facility licensee and facility name. Adding an addendum/cover page to the existing Admissions Agreement works, but executing an Admission Agreement for the current licensee and facility is ideal. Residents' latest medical assessments are dated 2022, 2023, 2024, and 2025 respectively; some assessments are missing fields of assessment and diagnosis. LPA discussed with Admin change to regulation as of 1/1/25. All residents regardless of diagnosis require an annual medical assessment. Appraisals for residents show a signature date of October of 2024 but an assessment date of March of 2024. LPA advised Admin to complete appraisals annually and be sure to change the assessment date on the front page. LPA advised to not reuse old assessments.

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NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025
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: GRAND CRU SENIOR CARE CORP
FACILITY NUMBER: 496804250
VISIT DATE: 08/05/2025
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LPA also advised if the responsible party does not sign, be sure to document appraisal was provided via email or fax. Resident (R4) was on hospice but graduated off hospice in January 2025. Per Admin and caregiver, R4 cannot reposition herself with side rails. LPA advised Admin of Care of Bedridden residents regulation. LPA advised since R4 is no longer on hospice he will need to obtain bedridden fire clearance. Admin will update facility sketch and submit to LPA along with written request for bedridden fire clearance. LPA will then initiate request for fire clearance inspection. Per LPA review of R4 appraisal, Admin planned to get hoyer lift in order to transfer R4. However, Admin advised currently a hoyer lift is not needed as caregiver can transfer R4 by themselves. In LPA's observation, caregivers have a small physical stature and it appears would have difficulty transferring residents without alone.

LPA review of resident records indicate that three [3] of six [6] residents are fall risks and at least two [3] out of six [6] require assistance with mobility and assistance with toileting needs. Considering LPA's observation of staffing and residents not having a current medical assessment, Admin and LPA discussed resolving questions of adequate staffing by obtaining a current medical assessment for all residents. Admin agrees to obtain current medical assessment specifically using the LIC602A form, in a timely manner. LPA's review of R3's medical assessment shows that they have a foot ulcer. Per Admin, R3 does not have an ulcer but instead as a condition which requires a brace, but resident refuses to wear brace. LPA unable to view R3's foot. When Admin gets current medical assessment for R3, medical assessment to include foot ulcer staging. Admin to forward all medical assessments, in a timely manner, to LPA. LPA may then return to review staffing, fire clearance, and review staging of ulcer for R3, if needed.

At approximately 12:30pm LPA conducted review of five [5] staff records. All required documentation present. LPA discussed with Admin training subject matter topics in regulation. LPA advised to be sure that training curriculum includes all subject matters specified in regulation.

At approximately 3:00pm LPA and Admin conducted a spot check of medication and medication records. Medication is centrally stored in a locked closet. LPA observed bottle of Melatonin to be empty. Admin advised he is waiting on the family to provide more. LPA advised it is the responsibility of the facility to ensure

Continues on 809C(3)...

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025
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: GRAND CRU SENIOR CARE CORP
FACILITY NUMBER: 496804250
VISIT DATE: 08/05/2025
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all residents that do not manage their own medication have their medication administered in line with their current physician's orders, whether or not family has provided it. Admin will forward facility's plan of operation to LPA for review of prescription and medication management policy. LPA discussed with Admin maintenance of a PRN MAR with requirements in regulation, including outcome of PRN administration. LPA also discussed with Admin making sure that Centrally Stored Medication Log (CSML) matches the current physician's orders exactly, including specifications of dosing, grams/milligrams/etc, and administration.

Tejpal Sekon Administrator Certificate 6072043740 expires 3/8/26.


LPA and Administrator discussed facility's Infection Control Plan and Emergency Disaster plan. Updates were made recently and Admin will send in updated copies to CCL.

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
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 Administrator. 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.

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/05/2025 04:15 PM - It Cannot Be Edited


Created By: Christi Coppo On 08/05/2025 at 03:54 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: GRAND CRU SENIOR CARE CORP
FACILITY NUMBER: 496804250

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(a)(2)(D)
Infection Control Requirements
(a) A licensee shall ensure that infection control practices are maintained as follows: (2) Environmental cleaning and disinfection activities shall be performed following the manufacturers' instructions for proper use of the cleaning and disinfecting products.  These activities shall be completed, at a minimum, as follows:  (D) Facility items that cannot be disinfected shall be discarded immediately in an appropriate waste receptacle with a tight-fitting cover or otherwise made inaccessible to human contact or transmission. 

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 LPA observed feces soiled brief in half bath across from rooms #5 and #6 in a trash can without a lid and urine soiled brief with used chucks in main bath garbage without a lid, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/19/2025
Plan of Correction
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Facility to add tight fitting covers for all garbage cans that contain items that cannot be disinfected. Facility to submit picture of garbage cans to CCL by plan of correction due date.
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:
Christi Coppo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2025


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