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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045002440
Report Date: 10/17/2024
Date Signed: 10/17/2024 12:25:45 PM


Document Has Been Signed on 10/17/2024 12:25 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 LIVINGFACILITY NUMBER:
045002440
ADMINISTRATOR:DAVIS, IRENEFACILITY TYPE:
740
ADDRESS:55 CONCORDIA LNTELEPHONE:
(530) 533-7857
CITY:OROVILLESTATE: CAZIP CODE:
95966
CAPACITY:150CENSUS: DATE:
10/17/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Irene Davis - Executive DirectorTIME COMPLETED:
01:00 PM
NARRATIVE
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10/17/2024 10:00 AM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with Executive Director Irene Davis. Today’s visit is regarding an incident that was reported to licensing on 10/09/2024.

On 10/092024, the regional office received an incident report regarding a report of financial abuse from a staff to a resident. The local police department had contacted the facility attempting to locate Staff 1 (S1) because she had cashed a check for $2500.00 that belongs to Resident 1 (R1). The resident (no dementia diagnosis) stated they had not given S1 a check and the police have determined that the check was not written by R1. R1 states they are missing two check books. The facility has secured all of R1's checks. R1 states that on 10/07/2024 S1 called them twice and hung up.

S1 no longer has access to the residents, was placed on administrative leave immediately, and was terminated from employment on 10/09/2024 as a result of the incident.

As a result of the investigation, it was determined that Staff 1 (S1) stole a check from S1’s room, forged and cashed the check and withdrew funds from R1’s checking account which constitutes financial abuse of the resident.

Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the allegation that staff financially abused a resident is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC809D. Appeal rights were provided. Exit interview was conducted and the report was provided to administrator Irene Davis.

SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2024
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 10/17/2024 12:25 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: 10/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/31/2024
Section Cited
CCR
87468.2(a)(8)

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87468.2(a)(8) Additional Personal Rights of Residents in Privately Operated Facilities (a)(8) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement is not met as evidenced by:
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Licensee agrees to conduct staff training for all current staff regarding the penalties for perpetrating financial abuse of a resident and the consequences and penalties they will face if they do so. Additionally licensee agrees to hold staff training regarding accepting gratuities and gifts from residents and consequences of doing so.
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Based on document review and interviews the licensee did not protect R1 from being financially abused by S1 resulting in significant financial loss to R1. This poses an immediate Health, Safety and Personal Rights risk to clients in care.
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Licensee shall submit staff training sign in sheet as proof of correction.

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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 CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2024
LIC809 (FAS) - (06/04)
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