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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 041370643
Report Date: 10/03/2023
Date Signed: 10/03/2023 11:20:58 AM


Document Has Been Signed on 10/03/2023 11:20 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 HOUSEFACILITY NUMBER:
041370643
ADMINISTRATOR:FOZ, ROMERICOFACILITY TYPE:
740
ADDRESS:966 KOVAK COURTTELEPHONE:
(530) 342-7002
CITY:CHICOSTATE: CAZIP CODE:
95973
CAPACITY:20CENSUS: 12DATE:
10/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Administrator- Meryl Foz TIME COMPLETED:
11:45 AM
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On 10/3/2023, Licensing Program Analyst (LPA) Jaynae Boyles, arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA met with the Administrator, Meryl Foz and explained the purpose of the visit.

LPA Boyles and Administrator toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, garage, backyard, shed, and common restrooms. LPA observed an activity calendar and activity materials, ie board games, puzzles, and books. LPA observed the facility to be clean, in good repair and odor-free and each bathroom to have the necessary grab bars, non-skid flooring or shower chair, paper towels, trash can with lids and 20-second hand-washing poster. Hot water measured at 117.5 degrees in restrooms, shower rooms and resident bedrooms.

Facility has a 2-day perishable and a 7-day non-perishable amount of food and sharps to be locked. Freezer temperature is maintained a zero degrees Fahrenheit and the refrigerator is maintained at 45 degrees Fahrenheit. This area was clean and in good repair.

LPA toured the backyard which had an outdoor furniture which is shaded. LPA observed a shed which is locked and is utilized to store lawn equipment. This area was clean and in good repair.


LPA observed three (3) fire extinguishers which were last services in August of 2023. LPA observed fire detectors, and carbon monoxide detectors in resident rooms. .
In the areas toured no immediate health, safety, or personal rights violations were observed.

LPA reviewed a total of five (5) residents' files and five (5) staff files.

Several topics were discussed. No deficiencies are being cited as a result of today’s inspection. Exit interview conducted and copy of report left at the facility.














SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Jaynae BoylesTELEPHONE: (916) 917-3040
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2023
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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