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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 045920039
Report Date: 08/27/2025
Date Signed: 08/27/2025 10:19:38 AM

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
06/02/2025 and conducted by Evaluator Sarah Benson
COMPLAINT CONTROL NUMBER: 59-AS-20250602144454
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: 15DATE:
08/27/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Resident Care Cordinator Dakota NewmanTIME COMPLETED:
10:26 AM
ALLEGATION(S):
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Facility mismanaged resident's medications.
INVESTIGATION FINDINGS:
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On 8-27-25 Sarah Benson, Licensing Program Analyst (LPA) arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 06-02-25. LPA Benson met with Administrator Michael Foz and Resident Care Cordinator Dakota Newman and explained the purpose of the visit.

During the interview process two staff persons were interviewed. The following documents were received and reviewed: staff list with telephone numbers, staff schedules for May and June 2025, MAR, medical records, care notes and incident reports.




Continued on LIC9099C, LIC9099D.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sarah Benson
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2025
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 3
Control Number 59-AS-20250602144454
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 COMMONS
FACILITY NUMBER: 045920039
VISIT DATE: 08/27/2025
NARRATIVE
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The document review revealed that staff had faxed medications request to R1’s doctor on 5-13-25, 5-15-25 and 5-20-25. The Administrator reported on May 22 I went to the VA in Chico and picked up two missing medications. Review of the Medication Administration Record revealed the two medications were documented and administered to the resident at this time. Further document review revealed the resident went without several other medications for seven days and two medications were never recorded as received or given.

Durning interviews staff reported a visit from the VA nurse on 5-21-25. After a review of the residents’ medications, the nurse reported that a medication was not listed by the doctor’s admission, standing orders. Documentation of doctors’ orders dated 5-9-25 did not have the missing resident medication listed as a standing order. On 5-21-25 the nurse stated the missing medication would be delivered by mail.

Staff reported on 5-25-25 the nurse phoned to see if the resident had received his missing medication per the visit and conversation on 5-21-25. Staff had stated no they had not received the package. The nurse reported to staff I have record that the medication had been delivered on 5-23-25. Staff reported reviewing security film footage and discovered a package was delivered from UPS on 5-23-25. Staff reported the package was found in the medication room in a drawer on 5-25-25 after security film review. Staff stated when the package was delivered it had the residents name on it so the staff declined to open the package. Staff reported that the facility doesn't usually get medication from UPS and the staff that took the package didn't realize the package was medication.
Document review revealed this medication was delivered 5-23-25 and discovered on 5-25-25. Record review of the Medication Administration Record revealed the medication was not recorded or administered to the resident.

Based on investigation observations, record review(s) and interviews which were conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099D. Appeal rights were explained and provided to the facility representative listed above and exit interview conducted. If any of the cited deficiencies are not corrected by the noted due date, civil penalties may be assessed.


SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sarah Benson
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 59-AS-20250602144454
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 COMMONS
FACILITY NUMBER: 045920039
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/03/2025
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care. (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance...: (4) The licensee shall assist residents with self-administered medications as needed.
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Administrator will spot check residents medications weekly.
Administrator will have professional medication training for all staff.
Administrator will notify LPA when completed.
Administrator will send a copy of staff training with staff signatures.
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This requirement was not met as evidenced by: Based on interviews and records reviewed, the licensee/administrator did not ensure that a resident received his medication, when the medication was prescribed. This poses an immediate Health and Safety risk to residents in care.
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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.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sarah Benson
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3