Granite Spring Care Home 4

Type of visit: Required - 1 Year

LPA Hiratsuka, conducted this unannounced annual visit. LPA toured the facility with Caregiver. Administrator showed up a short time later and completed visit with LPA. This facility has a fire clearance for six non-ambulatory residents. This facility has four resident rooms. Three of the rooms may be shared and one is private. However, if the three rooms are going to be shared, then the private room shall not be used for residents. To the left of the main entrance is a doorway leading to a hallway that leads to the bedrooms. There is a common half bathroom, a common full bathroom, and laundry room, and the four bedrooms. The largest of the resident rooms has a full private bathroom and an exit to the outside. To the right and front of the main entrance is the kitchen, dining, and main common areas. There is also a door leading to the garage from the kitchen. The backyard was inspected. There is a covered patio area and the backyard is well maintained. There is a gate on the same side as the garage. There are locked cabinets for sharp knives and medications. The cabinets in the laundry room are locked. Multiple topics were discussed. The following shall be updated and submitted to Community Care Licensing by 10/15/2023: -LIC 500 facility personnel or staff schedule -LIC 610 emergency disaster plan -LIC 308 designation of administrative responsibility No deficiencies cited.the state’s words, verbatim · CDSS document, Sep 27, 2023

Type of visit: Required - 1 Year

On November 8, 2022 at 10:30am, Licensing Program Analyst (LPA) De Anna Williams-Lyons arrived unannounced to conducted an Annual Inspection, LPA met with administrator Tatyana Nesteruk, who helped LPA with the inspection. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of g COVID-19 infection to affirm no COVID-19 related symptoms and completed a facility risk assessment. LPA ensured she applied hand sanitizer before entering the facility and a N-95 mask was worn for Personal Protective Equipment. LPA and Tatyana completed the infectious Control questionnaire with no issues or concerns. The Administrator certificate expires 4/27/2024. The current census is 4. The facilities Administrator’s Certificate, Emergency Disaster Plan, Resident’s Rights and Facility Sketch was available for viewing. The room temperature was 74 degrees F which is within range. LPA inspected the interior and the exterior of the facility including the common living spaces, the kitchen, resident bedrooms and bathrooms. In the kitchen area, cabinets and drawers were reviewed. Knives and sharp objects were reviewed to make sure that they were locked and made inaccessible to the residents at all times. LPA observed there to be a sufficient amount of 2-day perishable and 7-day non-perishable food. Hot water temperatures were taken and measured at 120 degrees F, which is within the allowed range of 105-120 degrees. There’s appropriate lighting throughout the facility. To continue see 809-C The facility is a one story home. Living rooms, dining room, and areas designated for resident use were toured. Furniture and furnishings were observed to be sufficient and in good repair. Resident bedrooms and bathrooms were toured. There are 4 Bedrooms .and 3 All rooms had the required items of furniture. Window screens were on and in good repair. Bathrooms were clean, sanitary and odorless and consisted of grab bars and non-skid mats. Hot water temperature is 106 degrees F. The sink, toilet, bathtub and shower operate properly. The facility has a sufficient supply of linens, towels, bedding, etc. for residents in care. Washer and dryer was present and operating properly. Toxic substances, laundry and cleaning supplies are inaccessible. There’s a centralized storage area for resident’s medication. Medication cabinet was locked. First aid kit was present and included the required scissors, tweezers, thermometer and guide. Fire alarms, smoke alarms, and carbon monoxide detectors operate properly. Fire extinguisher is maintained and ready for emergency use. LPA inspected the exterior grounds of this facility. There are no bodies of water on the premises. The perimeter fence, side gates, and latches were in good repair. Passageways are free of obstruction and potential hazards. Per California Code of Regulations, Title 22, No citations were issued. The Administrator shall submit updated copies of the LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610D the Emergency Disaster Plan, and copy of current Liability Insurance to update the facility file. Administrator shall submit the listed documents to Licensing no later than December 8, 2022. An exit interview was conducted and a copy of this report was given to Tatyana..the state’s words, verbatim · CDSS document, Nov 8, 2022

Type of visit: Required - 1 Year

On November 5, 2021, at 10:10am, Licensing Program Analyst, LPA DeAnna Williams-Lyons arrived unannounced to conduct a required annual inspection. LPA met with Natalie Oaksha , Administrator, and informed her the reason for the visit. Prior to initiating the inspection LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; and completed a facility risk assessment. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: mask. LPA completed the inspection tool questionnaire with Natalie with no issues or advisories to report. LPA observed the following: This is a 4 bedroom 2.5 bathroom home. Administrator certificate is valid and expires 4/10/2022 . First aid kit fully stocked and ready for emergency use. Fire extinguishers fully charged. Smoke alarms and Carbon Monoxide detector are working Hot water temperature is in the proper range. The facility temperature is 76 degrees F. Common areas were clean and in good repair. Bedrooms had required furniture and lighting. Facility has the required (2) day perishable supply of food and (7) supply of non-perishable food. Medication was properly stored and locked away. There are no bodies of water on the premises. To continue see 809-C... LPA reviewed 1 staff file and 1 resident file. Staff files have all the proper signatures and the facility is conducting training as required. Resident files also had all the required documents with the proper signatures. As a result of this visit, no deficiencies were cited, per Title 22 Regulations, Division 6. Administrator shall submit the following documents to update the Regional Office files: The documents shall be submitted to Community Care Licensing by 12/05/2021: -LIC 500 facility personnel or staff schedule -LIC 610 emergency disaster plan -LIC 308 designation of administrative responsibility -copy of liability insurance -updated facility sketch Exit interview conducted and a copy of this report given to Natalie.the state’s words, verbatim · CDSS document, Nov 5, 2021