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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002844
Report Date: 02/18/2025
Date Signed: 02/18/2025 11:35:20 AM

Document Has Been Signed on 02/18/2025 11:35 AM - 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 SIDE HOME CAREFACILITY NUMBER:
315002844
ADMINISTRATOR/
DIRECTOR:		CERVANTES, SUSANFACILITY TYPE:
740
ADDRESS:2255 CENTRAL AVETELEPHONE:
(916) 789-1875
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY: 6CENSUS: 4DATE:
02/18/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:35 AM
MET WITH:Susan Cervantes, AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Cassandra Mikkelson arrived unannounced and met with Administrator Susan Cervantes, to conduct an annual inspection utilizing the inspection tool.

LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. LPA observed four (4) resident rooms and two (2) common area bathrooms. LPA observed rooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition, properly maintained, and the hot water temperature was observed to be 113.1 degrees F.

LPA checked the kitchen area for the ability to prepare and store food. Care home has required (2) two day perishable and (7) seven day non-perishable food supply on hand. Smoke detectors and carbon monoxide detectors are operational in the care home. Fire extinguishers and first aid kit are maintained and ready for emergency use. LPA checked medication storage and found medications to be locked away and inaccessible to the residents. LPA reviewed four (4) resident files, two (2) staff files and resident medications.

Facility has a current copy of certificate of liability insurance and LPA obtained a copy.

As a result of this visit, no deficiencies were cited pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8. Exit interview was conducted with Administrator.

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cassandra Mikkelson
LICENSING EVALUATOR SIGNATURE: DATE: 02/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/18/2025
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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