045002440-8-3-2022-25-AS-RKNT-CGXQ8B-20220803115628

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 045002440
Report Date: 08/03/2022
Date Signed: 08/03/2022 11:57:02 AM

Document Has Been Signed on 08/03/2022 11:57 AM - It Cannot Be Edited

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 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:	08/03/2022
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	11:46 AM
MET WITH:	Irene Davis - administrator		TIME COMPLETED:	12:15 PM

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08/03/2022 11:45 AM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with administrator Irene Davis. The purpose of this visit was to conduct a case management investigation. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 Mask, gloves.

Today's meeting concerns an investigation into an incident report that was received from the facility on 07/28/2022 regarding an incident that occurred at the facility on 07/26/2022. It was reported that on 7/26/2022 Resident 1 (R1) made a statement of suicidal ideation and proceeded to attempt to throw themselves down a staircase at the facility. Staff witnessed R1 make the statement, realized R1’s intention and quickly prevented R1 from falling down the stairs. EMS and local police department were notified and responded, family and physician were notified. R1 refused care so EMS did not transport R1 to hospital. Police department determined there was no reason to transport R1 to hospital to be evaluated.

In order to prevent this from happening again the facility has moved R1 to the facility’s memory care unit in a secure environment for R1’s safety, R1 agreed to this. R1 has been placed on 1 to 1 care and R1’s care plan has been updated. The facility physician is going to adjust R1’s medications to help with depression. A behaviorist came in to see R1 and determined that R1 is not harmful to himself or anyone else, the behaviorist will come in to visit R1 on a regular basis. Facility also arranged for a therapy dog to come in to visit R1 on a regular basis and this has helped with R1's depression. Administrator has a meeting with the family scheduled to follow up regarding R1's current and ongoing care.

No deficiencies cited. Exit interview conducted and a copy of the report was emailed to administrator Irene Davis.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Rebecca Knight	TELEPHONE: (530) 895-4356
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022

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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