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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 097000124
Report Date: 04/28/2021
Date Signed: 04/28/2021 12:24:47 PM

Document Has Been Signed on 04/28/2021 12:24 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:APPLE COUNTRY CARE HOMEFACILITY NUMBER:
097000124
ADMINISTRATOR:FOSS, LAURAFACILITY TYPE:
740
ADDRESS:4330 HARNESS TRACTTELEPHONE:
(530) 644-3026
CITY:CAMINOSTATE: CAZIP CODE:
95709
CAPACITY: 7CENSUS: 3DATE:
04/28/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Mary HensleyTIME COMPLETED:
12:30 PM
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Case management visit regarding a special incident report where on 4/14/21, a resident (R1) had to call 911 to request assistance, as the resident could not get the staff member (S1) to assist her from the floor as she had slithered off of her bed. S1 had been sleeping in the facility and had to be awakened by the fire department personnel who responded to R1's 911 call. It was also confirmed that the boyfriend (BF1) of the staff member, was present in the facility at the time of this incident. It is the policy of the facility to have awake staff at all times.

See 809-D for deficiencies cited along with the accompanying civil penalty for having a person present in the facility, without a criminal record clearance.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Michael Smith
LICENSING EVALUATOR SIGNATURE: DATE: 04/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2021
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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Document Has Been Signed on 04/28/2021 12:24 PM - It Cannot Be Edited


Created By: Michael Smith On 04/28/2021 at 11:28 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: APPLE COUNTRY CARE HOME
FACILITY NUMBER: 097000124

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/28/2021
Section Cited
CCR
87355(a)

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87355(a)-Criminal Record Clearance-The Department shall conduct a criminal record review of all individuals specified in Health and Safety Code section 1569.17 and shall have the authority to approve or deny a facility license, or employment, residence, or presence in the facility, based upon the results of such review.

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S1 was terminated from employment. All persons who are present in the facility, based on the facts in this case, shall be fingerprinted and criminally cleared.

***Deficiency cleared during visit***
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This requirement is not met as evidenced by: Based on witness statements, licensee did not have BF1 criminally cleared to be present in the facility and is in violation of this section. This poses an immediate health and safety risk to residents in care. Immediate civil penalty of $100.
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Type B
04/28/2021
Section Cited
CCR87411(a)

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87411(a)-Personnel Requirements-General- Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by: Based on witness interviews, A resident had to call 911 for assistance as the caregiver was not able to assist, as the staff
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S1 was terminated from employment. All facility staff shall provide the services necessary to meet the residents needs. .

***Deficiency cleared during visit***
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was found sleeping by the fire department personnel who responded to the 911 call from R1. Licensee did not provide adequate care and supervision for the resident and is in violation of this section. This poses a potential 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.
SUPERVISOR'S NAME:Laura Munoz
LICENSING EVALUATOR NAME:Michael Smith
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2021


LIC809 (FAS) - (06/04)
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