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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002974
Report Date: 12/30/2024
Date Signed: 12/30/2024 12:23:11 PM

Document Has Been Signed on 12/30/2024 12:23 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:COUNTRY OAKS SENIOR LIVINGFACILITY NUMBER:
455002974
ADMINISTRATOR/
DIRECTOR:		JOHNSON, MELISSAFACILITY TYPE:
740
ADDRESS:847 COUNTRY OAK DRTELEPHONE:
(530) 605-4437
CITY:REDDINGSTATE: CAZIP CODE:
96003
CAPACITY: 4CENSUS: 4DATE:
12/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Administrator, Melissa Johnson
Prospective Administrator, Gwen Simons		TIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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On December 30, 2024 at approximately 10:00 AM, Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Country Oaks Senior Living for the purpose of conducting a Required 1 year inspection. LPA was greeted at the door by Administrator, Melissa Johnson, and was granted access into the facility. Also participating in this Required 1 year inspection was Prospective Administrator, Gwen Simons. Clients are at their respective Day Programs.

LPA and Administrative staff toured the facility. LPA observed the facility to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguishers were found to be last charged on October 2024 at the time of the inspection. All smoke detectors and carbon monoxide detectors were tested and found to be operational. Water temperature in facility bathrooms measured at 106 degrees, within acceptable range of 105 to 120 degrees F. LPA observed sufficient perishable and non-perishable foods located in the kitchen. There are special provisions made for individuals with special dietary needs. Food menu was presently available for viewing during the inspection. Medications were centrally stored and locked. Cleaning products and other toxins are located in the laundry room that was locked and inaccessible to residents in care. There was a supply of linens, cleaners, hygiene products and paper products available for residents. All bathrooms designated for residents in the common areas at the facility were supplied with individual paper towels and hand soap. Bathrooms in resident’s rooms have a towel and soap. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. A tour of bedrooms were conducted, and bedrooms inspected have lighting and appropriate furnishing. LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms of COVID-19 or other infectious diseases are present in the facility. LPA reviewed the infection control plan. First Aid kit was inspected and found to be appropriate during the inspection. Emergency Disaster Drill was last conducted on December 2024.

(Report continued on LIC 809C)
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 12/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/30/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 OAKS SENIOR LIVING
FACILITY NUMBER: 455002974
VISIT DATE: 12/30/2024
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LPA reviewed 4 of 4 resident files and was observed to be appropriate during the inspection. LPA reviewed 4 of 4 staff files and found that 1 out of the 4 staff member files that were reviewed did not have the required annual training (See LIC 9102-Technical Advisory). LPA educated the Administrator on the importance of ensuring that ALL staff that provide care and supervision have the necessary hours as outlined in Title 22 Regulations.

LPA requested the following documents to be sent via email:

LIC 500- Personnel Report
LIC 308- Designation of Facility Responsibility
LIC 309- Administrative Organization
Most up-to-date Liability insurance
Emergency Disaster Plan
Control of Property
Register of residents

No deficiencies were cited during today's Required 1 year inspection. Exit interview was conducted and a copy of this report was signed and given to the Administrator.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2024
LIC809 (FAS) - (06/04)
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