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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 315920101
Report Date: 01/10/2025
Date Signed: 01/10/2025 11:21:28 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/23/2024 and conducted by Evaluator Talwinder Bains
COMPLAINT CONTROL NUMBER: 59-AS-20241223133123
FACILITY NAME:COUNTRY LIVING SENIOR CAREFACILITY NUMBER:
315920101
ADMINISTRATOR:GROZAV, MARIAFACILITY TYPE:
740
ADDRESS:425 WISE ROADTELEPHONE:
(916) 956-8362
CITY:LINCOLNSTATE: CAZIP CODE:
95648
CAPACITY:6CENSUS: 4DATE:
01/10/2025
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator, Maria GrozavTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Facility did not follow medication orders.
INVESTIGATION FINDINGS:
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On 01/10/25, Licensing Program Analyst (LPA) Talwinder Bains arrived unannounced to deliver complaint findings for allegation listed above. LPA met with Administrator, Maria Grozav during today's visit and explained the purpose of the visit.

The department conducted records review ,facility observations and interviews with staff and residents to investigate the complaint.



**Report continued on LIC9099-C**
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 59-AS-20241223133123
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
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 CARE
FACILITY NUMBER: 315920101
VISIT DATE: 01/10/2025
NARRATIVE
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***Report continued from 9099...........

Allegation- Facility did not follow medication orders.

Department conducted record review, facility’s observations and interviewed four residents and two staff members regarding this allegation. Four resident interviews reflected that staff were giving residents medications per their physician’s orders and there were no issues indicated. Two staff interviews indicated that staff were following physician’s orders and administering resident’s medications accordingly. Record review for medications management for December 2024 for two residents reflected that facility was administering resident’s medications per their physicians’ orders and keeping the required documentation per Regulations. Record review for resident, R1 who was admitted to facility on 12/01/24 reflected that R1 was sent to the ER two times between 12/01/24 -12/20/24 due to change in condition. It was learnt that each time R1 returned from hospital, there were medications adjustments by hospital staff and there were some medication errors which were by hospital staff but were addressed and corrected immediately once facility staff and R1s responsible party brought up to hospital staff and R1s physician. It was evaluated that facility was operating under RCFE guidelines and were managing R1s medications orders as ordered by R1s physician. Based on this gathered information, this allegation was found to be UNSUBSTANIATED.

A finding that a complaint allegation is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.



Exit interview was conducted and copy of the report has been provided.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2