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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804250
Report Date: 09/02/2026
Date Signed: 09/02/2026 05:03:04 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/02/2026 05:03 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: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:
09/02/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:55 PM
MET WITH:Tejpal Sekhon, licenseeTIME VISIT/
INSPECTION COMPLETED:
05:17 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by caregiver. Licensee and Administrator Tejpal Sekon arrived later. Tejpal Sekon Administrator Certificate 7036726740 03/08/2028. Facility currently has six (6) residents in care none of which are currently on hospice.

LPA toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed food present but not enough for a 2 day supply of perishable or a 7 day supply of non-perishable food sufficient for six (6) people. Licensee explained that his restocking day is on Thursdays. LPA advised, to remain in compliance, the facility should be stocked with enough food to meet regulation on any given day, including days right before restock. LPA found stalks of celery to be brown and yellow and wilted. LPA observed head of lettuce to have black and gray spots as well as wilting, caregiver threw away both lettuce and celery immediately. Caregiver stated that food was to be thrown in the compost but had yet to have a chance to pull it from the refrigerator and put out in the compost. LPA observed bag of cereal to be open and unsealed inside open cardboard box, caregiver immediately put in a ziplock to seal. LPA advised to be sure that all food capable of becoming stale be sealed appropriately. LPA kitchen cabinet under sink to be locked. All other cleaning products and laundry soaps are located in the cabinet and inaccessible to residents in care.

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 bathrooms had required bath mats and grab bars. Water temperature in sinks measured at 111.4 degrees F in the kitchen and 110.2 degrees F in the bathroom used by residents, both of which are within the allowable range of 105 to 120 degrees F.

Continued on 809C...
Victoria Bertozzi
Christi Coppo
DATE: 09/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/02/2026
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: GRAND CRU SENIOR CARE CORP
FACILITY NUMBER: 496804250
VISIT DATE: 09/02/2026
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Continued from 809...

Fire extinguishers showing as fully charged. Facility’s last quarterly disaster drill was conducted on July 15, 2026. Facility has a backup generator for use during a power outage.

LPA observed light above sink by rooms #5 and #6 to not work. Per caregiver it just broke today. LPA observed kitchen slider door to be missing a screen. Licensee will replace immediately.

LPA conducted a review of six (6) out of six (6) resident files and six (6) staff records. Three (3) residents did not have current appraisals on file, all were dated 2024 (deficiency cited, see 809 D). LPA discussed Health and Safety Codes 1569.625 and 1569.69 for staff training requirement hours and subjects as well as and medication training hours as subjects.

LPA and licensee conducted a spot check of medication and medication records. Medication is centrally stored in a locked closet. LPA went over requirements for Centrally Stored Medication Log (CSML) and PRN MAR. LPA and licensee discussed ensuring date started is recorded on CSML and on the bottle or bubble pack itself. LPA advised all PRNs must also be listed on the CSML.

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

DATE: 09/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/02/2026 05:03 PM - It Cannot Be Edited


Created By: Christi Coppo On 09/02/2026 at 04:40 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: 09/02/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/16/2026
Section Cited
CCR
87463(a)

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(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first....
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Facility to complete current appraisals and send to CCL by plan of correction due date.
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This requriement not met by licensee as evidenced by: R1, R2, and R3 all had appraisals dated 2024, which poses an potential health, safety, and/or personal rights risk to resident in care.
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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: 09/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2026


LIC809 (FAS) - (06/04)
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