045002440-9-28-2023-59-AS-RKNT-CW4RUV-20230928132035

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 045002440
Report Date: 09/28/2023
Date Signed: 09/28/2023 01:20:43 PM

Document Has Been Signed on 09/28/2023 01:20 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 CREST ASSISTED LIVING		FACILITY NUMBER:	045002440
ADMINISTRATOR:	DAVIS, IRENE		FACILITY TYPE:	740
ADDRESS:	55 CONCORDIA LN		TELEPHONE:	(530) 533-7857
CITY:	OROVILLE	STATE: CA	ZIP CODE:	95966
CAPACITY:	150	CENSUS: 68	DATE:	09/28/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	12:35 PM
MET WITH:	Irene Davis - administrator		TIME COMPLETED:	01:30 PM

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

09/28/2023 12:35 M Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with Administrator Irene Davis. Today’s visit is regarding an incident that occurred on 09/16/2023 and was reported to licensing on 09/23/2023.

It was reported that on 09/16/2023 at 7:10 PM Care staff was transferring Memory Care Resident 1 (R1) to the toilet and R1 slipped and fell on their bottom. Staff assessed R1 for injuries, none were noted but R1 complained of hip pain. The Med Tech called EMS and R1 was transported to a local hospital for evaluation and treatment. R1’s POA was notified. R1 was admitted to the local hospital to be treated for a compression fracture to their right hip. R1 will not be returning to the facility and will be admitted to skilled nursing as R1 is not cognitively aware enough to care for their hip and prevent further complications.

LPA interviewed administrator and Memory Care Director during the visit. LPA obtained documents during the visit. LPA will conduct telephone interview with staff and return for a follow up visit.

No deficiencies were cited as a result of today’s visit.

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca Knight	TELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 1