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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045002440
Report Date: 11/14/2024
Date Signed: 11/14/2024 03:56:45 PM

Document Has Been Signed on 11/14/2024 03:56 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:COUNTRY CREST ASSISTED LIVINGFACILITY NUMBER:
045002440
ADMINISTRATOR/
DIRECTOR:		DAVIS, IRENEFACILITY TYPE:
740
ADDRESS:55 CONCORDIA LNTELEPHONE:
(530) 533-7857
CITY:OROVILLESTATE: CAZIP CODE:
95966
CAPACITY: 150CENSUS: 59DATE:
11/14/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:45 PM
MET WITH:Irene Davis - Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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11/14/2024 03:45 PM Licensing Program Analyst (LPA) Rebecca Knight conducted an unannounced case management visit and met with Executive Director Irene Davis. Today’s visit is regarding an incident that was reported to licensing on 10/09/2024.

On 10/092024, the regional office received an incident report regarding a report of financial abuse from a staff to a resident. During the course of the investigation, it was learned that Staff 1 (S1) was not associated to the facility. On 10/08/2024 the CCLD Duty Officer pulled a Guardian Person Summary for Staff 1 (S1). This report revealed that S1 has been associated to four facilities, Country Crest Assisted Living is not on the list of facilities S1 has ever been associated to. On the same day, the duty officer pulled a Guardian Personnel list for Country Crest Assisted Living and S1 was not on that list. Therefore, S1 has never been associated to the facility and was working in the facility while not associated to the facility.

A civil penalty was assessed in the amount of $500.00 on 11/14/2024 on the attached LIC421.

Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the allegation that staff was working in the facility without being associated to the facility is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC809D. Appeal rights were provided. Exit interview was conducted and the report was provided to administrator Irene Davis.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE: DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2024
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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Document Has Been Signed on 11/14/2024 03:56 PM - It Cannot Be Edited


Created By: Rebecca Knight On 11/14/2024 at 12:11 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: COUNTRY CREST ASSISTED LIVING
FACILITY NUMBER: 045002440

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/28/2024
Section Cited
CCR
87355(c)

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87355(c) Criminal Record Clearance (c) A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another, or from Trust Line to a state licensed facility. This requirement is not met as evidenced by:
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Licensee is to submit in writing the date and details of S1 being terminated from employment. Additionally, the licensee shall review this regulation and submit a statement of understanding of the regulation. Both of these requirements are to be submitted to LPA by 11/28/2024.
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Based on file review the licensee did not comply with the section cited above as S1 was working in but was not associated to the facility which poses an immediate health, safety, or personal rights risk to persons in care.
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A civil penalty in the amount of $500.00 is being issued on 11/14/2024

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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.
SUPERVISOR'S NAME:Lauren Crocker
LICENSING EVALUATOR NAME:Rebecca Knight
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2024


LIC809 (FAS) - (06/04)
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