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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045920039
Report Date: 10/31/2023
Date Signed: 10/31/2023 04:03:22 PM

Document Has Been Signed on 10/31/2023 04:03 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:COUNTRY COMMONSFACILITY NUMBER:
045920039
ADMINISTRATOR:FOZ, MERYLFACILITY TYPE:
740
ADDRESS:962 KOVAK CTTELEPHONE:
(530) 342-7002
CITY:CHICOSTATE: CAZIP CODE:
95973
CAPACITY: 16CENSUS: 14DATE:
10/31/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Residental Care Director Nina Eads TIME COMPLETED:
04:15 PM
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On 10/31/2023 Licensing Program Analyst (LPA) Jaynae Boyles arrived at the facility announced to conduct a Pre licensing Inspection. LPA's met with Residential Care Director Nina Eads and explained the purpose of the visit.

LPA Boyles and Residential Care Director toured facility together to ensure that the facility is in compliance for seniors with dementia. Areas toured include but are not limited to: common areas, bedrooms, backyard, and restrooms. LPA observed the facility to be clean, in good repair and odor-free.

The facility was equip with required fire extinguishers, fire detectors and carbon monoxide detectors. The facility was stocked with the required two day perishable and 7 day non-perishable amount of food for residents and staff.

Component III waived.

The following items will need to be addressed prior to the facility getting licensed.

These corrections are also documented on the current license- 04500540 :

-Disaster Drills to be conducted every three months for a total of 4 in 12 months.

-Medical orders for residents with 1/2 rails (as postural supports)

Exit interview conducted and a copy of this report was left at the facility.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Jaynae Boyles
LICENSING EVALUATOR SIGNATURE: DATE: 10/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/31/2023
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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