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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045002440
Report Date: 11/14/2024
Date Signed: 11/14/2024 03:39:04 PM

Document Has Been Signed on 11/14/2024 03:39 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/
DIRECTOR:		DAVIS, IRENEFACILITY TYPE:
740
ADDRESS:55 CONCORDIA LNTELEPHONE:
(530) 533-7857
CITY:OROVILLESTATE: CAZIP CODE:
95966
CAPACITY: 150TOTAL ENROLLED CHILDREN: 0CENSUS: 59DATE:
11/14/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:15 PM
MET WITH:Irene Davis - Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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11/14/2024 02:30 PM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility and met with Administrator Irene Davis. The purpose of the visit was to conduct an unannounced case management visit to deliver and confirm orders to individual for immediate exclusion from all facilities.

LPA Knight served order of immediate exclusion effective 11/14/2024 and explained the "Immediate Exclusion" notice indicating that Staff 1 (S1) cannot be allowed to work, be present, and/or live in a CCL licensed facility, or have contact with clients in any residential facility or child day care licensed by the California Department of Social Services. Therefore, the Department orders the facility to remove S1 from any contact with residents and not allow S1 to be physically present in the facility. Administrator indicated they understood the notice and confirmed that S1 is currently not working at the facility.

Exit interview completed. Copy of report was provided to Executive Director Irene Davis. Signature on these forms acknowledges receipt of these documents.
Lauren CrockerTELEPHONE: (916) 261-4966
Rebecca KnightTELEPHONE: (530) 356-2841
DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2024
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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