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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 097000124
Report Date: 08/23/2021
Date Signed: 08/23/2021 07:27:11 PM

Document Has Been Signed on 08/23/2021 07:27 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: 7DATE:
08/23/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
06:17 PM
MET WITH:MaryTIME COMPLETED:
07:40 PM
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On 8/23/2021 at 6:17 PM, Licensing Program Analysts (LPAs) Kevin MkNelly and Jacob Williams arrived unannounced to the facility. LPAs followed necessary COVID-19 protocol by getting tested weekly, daily symptom check, and wore N95 respirators. LPAs met with Administrator Mary Hensley and Caregiver Joe Hurt.

LPAs spoke with Mary and Joe at length, illustrating the fact that Apple Country Care Home is currently in a "Red Zone" and should evacuate their residents. Staff stated that though resident belongings had been prepared for quick evacuation if needed, they will again be prepared for evacuation.

LPA Mknelly spoke with Licensee Mary Heider by phone. Licensee stated that if the evacuation order stands until tomorrow 8/24/21, all residents will be evacuated.

All resident families have been notified of the order and one resident, R1, left with family while LPAs were present.

No deficiencies are being cited as a result of todays inspection.

An exit interview was conducted with the Administrator. A copy of this report was provided to the facility. Signature of Administrator acknowledges receipt of this report.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Jacob Williams
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2021
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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