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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
045001608
Report Date:
01/04/2024
Date Signed:
01/04/2024 01:02:12 PM
Document Has Been Signed on
01/04/2024 01:02 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 HEARTS
FACILITY NUMBER:
045001608
ADMINISTRATOR:
LEONARD, CAROL
FACILITY TYPE:
740
ADDRESS:
7170 LOWER WYANDOTTE RD.
TELEPHONE:
(530) 589-2466
CITY:
OROVILLE
STATE:
CA
ZIP CODE:
95966
CAPACITY:
15
CENSUS:
2
DATE:
01/04/2024
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
12:39 PM
MET WITH:
Marissa Rogers - care staff
TIME COMPLETED:
01:00 PM
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01/04/2024 12:40 PM Licensing Program Analyst (LPA) Rebecca Knight arrived unannounced to deliver resident files that LPA had taken previous the same day in order to copy the files at the Chico District office. LPA met with care staff Marissa Rogers and explained the purpose of the visit.
This report confirms that LPA delivered the files back to the facility the same day.
No deficiencies cited during today's visit.
Exit interview conducted.
SUPERVISOR'S NAME:
Lauren Crocker
TELEPHONE:
(916) 261-4966
LICENSING EVALUATOR NAME:
Rebecca Knight
TELEPHONE:
(530) 356-2841
LICENSING EVALUATOR SIGNATURE:
DATE:
01/04/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/04/2024
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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