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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315920101
Report Date: 06/18/2024
Date Signed: 06/18/2024 11:55:14 AM

Document Has Been Signed on 06/18/2024 11:55 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 LIVING SENIOR CAREFACILITY NUMBER:
315920101
ADMINISTRATOR/
DIRECTOR:
GROZAV, MARIAFACILITY TYPE:
740
ADDRESS:425 WISE ROADTELEPHONE:
(916) 956-8362
CITY:LINCOLNSTATE: CAZIP CODE:
95648
CAPACITY: 6CENSUS: 0DATE:
06/18/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Maria GrozavTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Melissa Parks arrived on Tuesday June 18, 2024 to conduct an announced prelicensing visit.

The Compliance and Regulatory Enforcement Tool was used during today's inspection. This facility has a fire clearance for 4 nonambulatory and 2 bedridden residents, with a total capacity of 6. Facility has all required postings in the entry way.

LPA toured the facility with Administrator Maria. The following areas were inspected for compliance: kitchen, backyard, resident rooms, bathrooms, and common areas. Facility has current fire extinguishers and a full first aid kit. Medications are kept locked in a medication cart in the laundry room. Cleaning chemicals and knives/sharps are kept locked and inaccessible to residents. There is a gated pool in the backyard with a locked fence.

Component III has been completed at this time.

LPA observed the facility to have a secured perimeter which the recent fire inspection clearance does not show approval. LPA will work with the Central Applications Bureau so that the applicant is approved for a secured perimeter.

An exit interview was conducted with Administrator and a copy of this report will be left at the facility.

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Melissa Parks
LICENSING EVALUATOR SIGNATURE: DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/18/2024
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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