045002440-6-3-2024-59-AS-RKNT-D5VTWK-20240603150540

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 045002440
Report Date: 06/03/2024
Date Signed: 06/03/2024 03:06:12 PM

Document Has Been Signed on 06/03/2024 03:06 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: 61	DATE:	06/03/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Irene Davis - Executive Director		TIME COMPLETED:	03:00 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	06/03/2024 10:00 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with administrator Irene Davis 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 assisted living and memory care sections of the facility including resident rooms, common areas, activity room, laundry room, bathrooms, kitchen, storage areas. Staff and resident files were reviewed. All employees requiring background checks are cleared. Medications were reviewed. Medication is locked in locked med room. There is a schedule of recreational activities planned for the residents. Bedding, linens, and towels for residents were observed and found to be clean and in good repair. The facility was observed to be at a comfortable temperature. Common area was clean and in good repair. All bedrooms had required furniture, bedding, and lighting. 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 December 2023. Johnson Control comes in quarterly to inspect the fire alarm, sprinklers and smoke detector systems. They also come in annually to inspect the ansul system in the kitchen. There are no pools/bodies of water are on premises. Last disaster drill was conducted in February 2024, which was an active shooter drill, the facility has been conducting fire drills every 2 months. Continued on LIC809-C

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca Knight	TELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

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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Document Has Been Signed on 06/03/2024 03:06 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 CREST ASSISTED LIVING	FACILITY NUMBER: 045002440
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303

(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 in 3 of 10 bathroom lightbulbs and 1 of 10 bathroom fans which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/24/2024
	Plan of Correction
1 2 3 4	Licensee agrees to inspect all resident bathrooms to ensure that there are no lightbulbs that need to be replaced and also inspect all bathrooms fans to ensure that all are operating properly. Licensee agrees to submit inpection list with room numbers, inspection results and date of any required repair/replacement to LPA as proof of correction.

Type B

Section Cited

CCR

87411

87411 Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA record review the licensee did not comply with the section cited above in 4 of 4 staff files which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/24/2024
	Plan of Correction
1 2 3 4	LIcensee agrees to audit all staff files and determine which staff have not received first aid training or have expired training. In additiona licensee shall provide training to all staff who are not current and will submit proof of staff.

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: 06/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2024

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 CREST ASSISTED LIVING	FACILITY NUMBER: 045002440
	VISIT DATE: 06/03/2024

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LPA requested the following documents that need to be updated in the facility file:
LIC500 Personnel report

Deficiencies are being cited as a result of today's inspection and is included on the attached LIC809-D.

LPA inspected 10 resident rooms and observed that 1 of 10 bathroom fans was non-operational. LPA observed that lightbulbs in 3 of 10 resident bathrooms were either missing or non-operational.

LPA reviewed staff files and 4 of 4 staff files that were reviewed did not have current first aid certificates on file.

Exit interview conducted and copy of report was provided to administrator Irene Davis.

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca Knight	TELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2024

LIC809 (FAS) - (06/04)

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