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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 045002440
Report Date: 09/30/2025
Date Signed: 09/30/2025 05:07:39 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/26/2025 and conducted by Evaluator Rebecca Knight
COMPLAINT CONTROL NUMBER: 59-AS-20250926083648
FACILITY NAME:COUNTRY CREST ASSISTED LIVINGFACILITY NUMBER:
045002440
ADMINISTRATOR:DAVIS, IRENEFACILITY TYPE:
740
ADDRESS:55 CONCORDIA LNTELEPHONE:
(530) 533-7857
CITY:OROVILLESTATE: CAZIP CODE:
95966
CAPACITY:95CENSUS: DATE:
09/30/2025
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Angel Medrano - business office managerTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Physical plant violations - SUBSTANTIATED
INVESTIGATION FINDINGS:
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09/30/2025 03:00 PM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to conduct a complaint investigation. LPA met with Angel Medrano business office manager and explained the purpose of the visit.

LPA toured the facility, and conducted interviews during the visit.

Continued on LIC9099-C
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lauren Crocker
NAME OF LICENSING PROGRAM ANALYST: Rebecca Knight
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 59-AS-20250926083648
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 LIVING
FACILITY NUMBER: 045002440
VISIT DATE: 09/30/2025
NARRATIVE
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Physical plant violations - SUBSTANTIATED
During the visit LPA toured the facility and made the following observations:

It was reported that the licensee does not ensure facility air conditioner is in good repair. During a tour of the facility LPA observed that the first floor was very warm in the common area and office area. LPA took temperature readings that ranged between 82 and 85 degrees F. The air conditioning needs to be repaired.

Staff does not ensure facility flooring is in good repair. LPA observed that 1 resident room had kitchen flooring that is buckled and damaged. This flooring needs to be replaced.

Staff does not ensure facility sewage is in good repair. LPA observed floor drains in the main kitchen to be emitting a strong odor of sewage.

Staff does not ensure facility is free of insects. LPA observed gnats to be flying around in the common areas, dining room,resident rooms, and kitchen in the assisted living portion of the facility. On the memory care portion of the facility LPA observed gnats in the common area and small kitchen areas. LPA observed dead cockroaches in the drawers of the coffee bar on the first floor. LPA observed a live cockroach and a dead cockroach in the elevator room. LPA observed two sticky traps in the memory care kitchen that had multiple cockroaches on them.

LPA observed flood damage in the elevator room to include water stained linoleum, patches of missing linoleum, possible mold damage, and the bottom foot of sheet rock missing from one wall.

LPA observed floors to be sticky throughout the facility.

Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview conducted and a copy of the report was provided to Angel Medrano.
NAME OF LICENSING PROGRAM MANAGER: Lauren Crocker
NAME OF LICENSING PROGRAM ANALYST: Rebecca Knight
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 59-AS-20250926083648
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 LIVING
FACILITY NUMBER: 045002440
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/14/2025
Section Cited
CCR
87303(a)
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87303 (a) Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This was not met as evidenced by:
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Licensee agrees to submit timeline in which all repairs will be completed to LPA as proof of correction by 10/14/2025. As the repairs are completed the licensee shall update LPA by submitting invoices and photographs of the repairs.
Licensee agrees to remediate the gnat and cockroach infestation immediately and will submit pest control invoices to LPA as proof of correction.
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LPA observed common area to be too warm, gnats flying in all areas of the facility, dead and alive cock roaches in common area, memory care kitchen and utility room, 1 resident room flooring in disrepair, sewage smell in the main kitchen, flood damage in the elevator utility room sticky floor throughout the facility.
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LPA will follow-up with visits to ensure the repairs / pest control / cleaning have been completed.
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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.
NAME OF LICENSING PROGRAM MANAGER: Lauren Crocker
NAME OF LICENSING PROGRAM ANALYST: Rebecca Knight
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4