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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045920039
Report Date: 09/10/2024
Date Signed: 09/10/2024 02:45:30 PM

Document Has Been Signed on 09/10/2024 02:45 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/
DIRECTOR:		FOZ, MERYLFACILITY TYPE:
740
ADDRESS:962 KOVAK CTTELEPHONE:
(530) 342-7002
CITY:CHICOSTATE: CAZIP CODE:
95973
CAPACITY: 16CENSUS: 16DATE:
09/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:53 PM
MET WITH:Assistant Administrator- Michael Foz TIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On 09/10/2024, Licensing Program Analyst (LPA) Jaynae Boyles, arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA met with Facility Assistant Administrator, Michael Foz and explained the purpose of the visit.

LPA Boyles and Administrator toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, backyard, shed, and common restrooms. LPA observed the resident bedrooms to have all the required furnishings, working lights/fans with windows with screens. All resident bathrooms observed to be in working order and have the required supplies. LPA observed the resident showers to have bathroom the necessary grab bars, non-skid flooring or shower chair, paper towels, trash can with lids and 20-second hand-washing poster. Hot water was measured throughout the facility and it was within the regulation.

Facility has a 2-day perishable and a 7-day non-perishable amount of food. LPA observed medications sharps to be locked inaccessible to residents. LPA observed posted weekly menu and activities for the residents. LPA observed a plethora of supplies for the residents to use.

LPA observed fire extinguishers, fire detectors, and carbon monoxide detectors. LPA observed a complete first aid kit ready for emergency use. LPA observed a completed emergency disaster plan, and the required emergency disaster drills conducted within the last 12 months.

LPA observed the facility to be clean, in good repair and odor-free. In the areas toured no immediate health, safety, or personal rights violations were observed.

LPA reviewed a total of five (5) residents' files and five (5 ) staff files which contained all the required documentation.

No deficiency cited as a result of todays visit. Exit interviewed conducted.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Jaynae Boyles
LICENSING EVALUATOR SIGNATURE: DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/10/2024
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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