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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045002440
Report Date: 05/16/2023
Date Signed: 05/16/2023 01:24:17 PM


Document Has Been Signed on 05/16/2023 01:24 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



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: 73DATE:
05/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Irene Davis - Executive DirectorTIME COMPLETED:
01:45 PM
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05/16/2023 10:00 AM Licensing Program Analysts (LPAs) Rebecca Knight and Sarah Benson arrived at the facility unannounced to conduct a Required-1 Year inspection. LPAs met with Executive Director Irene Davis ( 6049915740 Exp. 11/13/2024 ) and explained the purpose of the visit.

LPAs and the executive director toured the facility together to ensure the health and safety of residents in care. Areas toured include but are not limited to resident rooms in both the Assisted Living and Memory Care units, common areas, bathrooms, kitchen, storage areas and dining room. Staff and resident files were reviewed.

Common area was clean and in good repair. All bedrooms had required furniture, bedding, and lighting. Bathrooms were clean and in good repair. Kitchen was clean and in good repair. Medication is locked in medication room.

Administrator certificate is current Fire extinguishers fully charged and were inspected in August 2022. Smoke detectors are all operational. All employees requiring background checks are cleared. All required postings are displayed within facility.

No pools/bodies of water are on premises. No firearms are on premises. Last disaster drill was conducted in March 2023 which was a Public Safety Power Shut Off drill the facility has been conducting drills every 4 months..

The following deficiencies were observed (See LIC 809D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.



Exit interview conducted and copy of report was provided to Executive Director Irene Davis.
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2023
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 05/16/2023 01:24 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833


FACILITY NAME: COUNTRY CREST ASSISTED LIVING
FACILITY NUMBER: 045002440

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(5)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in 2 of 4 resident rooms which poses a potential health, safety risk to persons in care.
POC Due Date: 06/06/2023
Plan of Correction
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Licensee agrees to inspect all resident rooms and ensure that non-skid mats or strips are installed in all resident showers/ bathtibs. Licensee shall submit inspection report including dates of inspection and room numbers confimring that all resident rooms meet this requirement.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan 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: 05/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2023
LIC809 (FAS) - (06/04)
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