045001608-7-19-2023-59-AS-RKNT-CTVP36-20230719105700

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 045001608
Report Date: 07/19/2023
Date Signed: 07/19/2023 01:34:48 PM

Document Has Been Signed on 07/19/2023 01:34 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: 9	DATE:	07/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Natasha Leonard - administrator		TIME COMPLETED:	11:00 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	07/19/2023 8:30 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with administrator Natasha Leonard ( ## 6057834740 exp. 11/30/2022 ) and explained the purpose of the visit. LPA Knight and the administrator toured the facility together to ensure the health and safety of residents in care. Areas toured include but are not limited to eight (8) rooms, common areas, four (4) bathrooms, kitchen, storage areas and back yard. Staff and resident files were reviewed. All employees requiring background checks are cleared. Administrator certificate expired on 11/30/2022, Administrator submitted for renewal within the required timeline but has not received new certificate. There is a schedule of recreational activities planned for the residents. Bedding, linens, and towels for clients were observed and found to be clean and in good repair. There is an adequate supply of toiletries for the clients. Medication is locked in a locked in a cart which is located in a locked room. The facility was observed to be at a comfortable temperature. Hot water measured between 105 – 120 degrees F. Common area was clean and in good repair. At the time of inspection there was flooring being replaced by a handyman. All bedrooms had required furniture, bedding, and lighting. Bathrooms were clean and in good repair. Kitchen was clean and in good repair. Food appears to be stored and prepared properly. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food. Fire extinguishers fully charged and were inspected in June 2023. Smoke detectors are all operational. No pools/bodies of water are on premises. No firearms are on premises. Last disaster drill was conducted in May 2023 which was an earthquake drill, the facility has been conducting fire drills monthly. Continued on LIC8090-C

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca Knight	TELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023

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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Document Has Been Signed on 07/19/2023 01:34 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(d)

Maintenance and Operation

(d) There shall be lamps or light appropriate for the use of each room and sufficient to ensure the comfort and safety of all persons in the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above in the hallway leading to resident bedrooms.which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/02/2023
	Plan of Correction
1 2 3 4	Licensee agrees to replace the ceiling lighting fixtures that are located in the hallway leading to resident bedrooms.

Type B

Section Cited

CCR

87307(d)(4)

Personal Accommodations and Services

(4) Stairways, inclines, ramps and open porches and areas of potential hazard to residents with poor balance or eyesight shall be made inaccessible to residents unless equipped with sturdy hand railings and unless well-lighted. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation the licensee did not comply with the section cited above in 2 areas of deck railing which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/02/2023
	Plan of Correction
1 2 3 4	LPA observed 2 open areas where the railing is missing on deck located on the south side of facility that residents could potentially walk or fall through. Licensee agrees to repair these open areas so resuident safety is assured.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca Knight	TELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2023

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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
	VISIT DATE: 07/19/2023

NARRATIVE

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The following deficiencies are being cited on the attached LIC809-D in accordance with California Code of Regulations, (Title 22).

Physical Plant/Environmental Safety - Type B: 87303(d) - Lighting in hallway that leads to resident bedrooms was observed to be very dim. Licensee agrees to replace lighting fixtures that are located in the ceiling of the hallway.

Physical Plant/Environmental Safety - Type B: 87307(d)(4) - LPA observed 2 open areas where the railing is missing on deck located on the south side of facility that residents could potentially walk or fall through. Licensee agrees to repair these open areas.

Physical Plant/Environmental Safety - Type B: 87303(a) - Weed abatement of at least 100' clearance of facility and general debris clean up.

Appeal rights were provided, and an exit interview conducted, a copy of the report was provided to administrator Natasha Leonard.

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca Knight	TELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 07/19/2023 01:34 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80703(a)

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation the licensee did not comply with the section cited above. LPA observed that weed abatement needs to be completed to ensure the facility has a mnimum of 100' of clearance of dried vegetation around the facility and a general debris clean-up needs to be completed which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/09/2023
	Plan of Correction
1 2 3 4	Licensee agrees to complete weed abatement ensure the facility has a mnimum of 100' of clearance of dried vegatation around the facility. Licensee agrees to complete a general debris cleanup and removal of items such a 3 discarded recliners and other rubbish.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca Knight	TELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2023

LIC809 (FAS) - (06/04)

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