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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315920101
Report Date: 06/27/2024
Date Signed: 06/27/2024 09:37:25 AM

Document Has Been Signed on 06/27/2024 09:37 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:
06/27/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Maria GrozavTIME VISIT/
INSPECTION COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA) Melissa Parks arrived on Thursday June 27, 2024 to complete an announced prelicensing visit.

LPA received an updated fire clearance for the facility which states 'this facility has a complete secured perimeter equipped with an electric gate installed with fire department access key switch'.

The facility appears to be in substantial compliance and ready for licensure. The license will be granted upon completion of a final review and approval from the Licensing Program Manager and the Central Applications Bureau. 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: 06/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2024
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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