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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 09:50:46 AM


Document Has Been Signed on 01/04/2024 09:50 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 HEARTSFACILITY NUMBER:
045001608
ADMINISTRATOR:LEONARD, CAROLFACILITY TYPE:
740
ADDRESS:7170 LOWER WYANDOTTE RD.TELEPHONE:
(530) 589-2466
CITY:OROVILLESTATE: CAZIP CODE:
95966
CAPACITY:15CENSUS: 2DATE:
01/04/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Marissa Rogers - care staffTIME COMPLETED:
10:00 AM
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01/04/2024 9:30 AM Licensing Program Analyst (LPA) Rebecca Knight arrived unannounced to conduct a health & safety visit due to facility plan to close. LPA met with care staff Marissa Rogers and explained the purpose of the visit.

LPA toured the facility withstaff. There are currently 2 residents living at the facility. All current residents were at home during today's inspection. LPA observed there was a 2-day perishable, 7-day non-perishable amount of food available. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA discussed a variety of topics.

LPA reviewed resident files and is taking resident files to Chico office to copy the files. LPA will return the resident files back to the facility immediately after copies are made (same day).

No deficiencies cited during today's visit.

Exit interview conducted.
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (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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