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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045002440
Report Date: 06/14/2021
Date Signed: 06/14/2021 11:31:16 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:COUNTRY CREST ASSISTED LIVINGFACILITY NUMBER:
045002440
ADMINISTRATOR:GOBIN-CUELLAR, PATRICIAFACILITY TYPE:
740
ADDRESS:55 CONCORDIA LNTELEPHONE:
(530) 533-7857
CITY:OROVILLESTATE: CAZIP CODE:
95966
CAPACITY:150CENSUS: 75DATE:
06/14/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Irene Davis, Executive DirectorTIME COMPLETED:
12:00 PM
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6/14/2021 11:00 AM, Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility to conduct a case management visit. LPA Knight met with Executive Director Irene Davis. The purpose of today's meeting is to conduct an investigation on an incident report that was received from the facility on 5/06/2021 regarding an incident that occurred at the facility on 5/05/2021.

It was reported that a resident was found unresponsive in the patio area of the Memory Care Unit due to heat and sun exposure resulting in need for medical attention.

LPA Knight conducted staff and resident interviews today. This incident requires additional interviews and investigation.

No deficiencies were cited on today's visit.

SUPERVISOR'S NAME: Rayna L BrysonTELEPHONE: (530) 895-5991
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 895-4356
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021
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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