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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 045920038
Report Date: 10/23/2025
Date Signed: 10/23/2025 04:30:15 PM

Unsubstantiated


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
10/13/2025 and conducted by Evaluator Kayla Adkison
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20251013140255
FACILITY NAME:COUNTRY HOUSEFACILITY NUMBER:
045920038
ADMINISTRATOR:FOZ, MICHAELFACILITY TYPE:
740
ADDRESS:966 KOVAK CTTELEPHONE:
(530) 342-7002
CITY:CHICOSTATE: CAZIP CODE:
95973
CAPACITY:20CENSUS: 16DATE:
10/23/2025
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Michael Foz, Administrator TIME COMPLETED:
11:45 AM
ALLEGATION(S):
1
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9
Staff are financially abusing a resident.
INVESTIGATION FINDINGS:
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2
3
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13
On October 23, 2025, Licensing Program Analyst (LPA) Kayla Adkison arrived at the facility unannounced for the purpose of opening up a complaint investigation. LPA was greeted by Administrator, Michael Foz, and explained the purpose of the investigation. During the visit, 16 residents were in facilty and 2 staff were providing direct care. LPA and Administrator toured the facility and made observations.

Allegation: Staff are financially abusing a resident.

During the course of the investigation, LPA interviewed one (1) resident (R1), R1's responsible party and two (2) staff. LPA requested the following documents: R1's current LIC 602 and R1's emergency identification sheet.

It was alleged that a staff had accepted monetary gifts from R1. All parties interviewed denied this allegation ever occured. R1's LIC 602 did not indicate a dementia diagnosis and the R1's responsible party (RP) indicated this allegation was not a possibility as RP is responsible for managing the resident's finances.

The administrator noted that an All-Staff meeting is already scheduled for October 30, 2025, where this topic will be discussed and staff will be reminded that they are not to take any monetary gifts from residents regardless of their mental diagnosis. The adminstrator indicated they will reach out to R1's responsible party regarding any changes in the resident's mental condition in regards to their finances.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report was provided to Administrator , Michael Foz, via email.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Kayla Adkison
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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