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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 041370643
Report Date: 10/11/2021
Date Signed: 10/11/2021 11:53:24 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:COUNTRY HOUSEFACILITY NUMBER:
041370643
ADMINISTRATOR:DORENZO, LYNETTEFACILITY TYPE:
740
ADDRESS:966 KOVAK COURTTELEPHONE:
(530) 342-7002
CITY:CHICOSTATE: CAZIP CODE:
95973
CAPACITY:20CENSUS: 16DATE:
10/11/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Macella Hardesty - Executive DirectorTIME COMPLETED:
12:00 PM
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10/11/2021 11:00 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Executive Director Marcella Hardesty and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted Executive Directpr and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Mask, gloves. Additionally, LPA Knight was screened by Marcella Hardesty.

LPA Knight and Ms. Hardesty toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident rooms, common bathrooms, dining room, visiting area and storage areas. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA Knight and Ms. Hardesty completed the infection control domain and facility was found to be in substantial compliance at this time.

No deficiencies are being cited as a result of todays inspection. Technical assistance was provided.

Exit interview conducted and copy of report was emailed to Marcella Hardesty.
SUPERVISOR'S NAME: Rayna L BrysonTELEPHONE: (530) 895-5991
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 895-4356
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2021
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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