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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045001608
Report Date: 01/05/2024
Date Signed: 01/05/2024 11:09:44 AM


Document Has Been Signed on 01/05/2024 11:09 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:
01/05/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Karrissa Hubbard - care staffTIME COMPLETED:
11:30 AM
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01/05/2024 10:30 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 Karrissa Hubbard and explained the purpose of the visit.

LPA toured the facility with staff. There are currently 2 residents living at the facility. All current residents were at home during today's inspection. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA discussed a variety of topics.

LPA plans to return ti the facility later today to meet with the administrator.

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: 01/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/05/2024
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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