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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045920038
Report Date: 10/25/2023
Date Signed: 10/25/2023 02:32:45 PM


Document Has Been Signed on 10/25/2023 02:32 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 HOUSEFACILITY NUMBER:
045920038
ADMINISTRATOR:FOZ, MERYLFACILITY TYPE:
740
ADDRESS:966 KOVAK CTTELEPHONE:
(530) 342-7002
CITY:CHICOSTATE: CAZIP CODE:
95973
CAPACITY:20CENSUS: 14DATE:
10/25/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Administrator- Meryl Foz TIME COMPLETED:
02:45 PM
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On 10/25/2023, Licensing Program Analyst (LPA) Jaynae Boyles and Ivan Avila arrived at the facility unannounced to conduct a Pre Licensing Inspection. LPA's met with Facility Administrator, Meryl Foz and explained the purpose of the visit.

LPA's and Administrator toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, garage, backyard, and common restrooms.

LPA's observed the facility to be clean, in good repair and odor-free. LPA's observed each bathroom to have the necessary grab bars, non-skid flooring or shower chair, paper towels, trash can with lids. The water in the bathrooms, resident restrooms and bathers measured above the required range.

LPA's checked the kitchen area for the ability to prepare and store food. Facility has required (2) two-day perishable and (7) seven-day non-perishable food supply on hand. LPA's observed knives, cleaning products and other toxins to be locked away and inaccessible to residents. LPA's observed three (3) fire extinguishers, fire detectors, and carbon monoxide detectors. In the areas toured no immediate health, safety, or personal rights violations were observed.


Several topics were discussed.

COMP 3 will be waived as the Administrator has sufficient experience.

As a result of this visit, no deficiencies were cited per California Code of Regulations, Title 22. Exit interview conducted and copy of report given

This facility is ready to be licensed.

SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Jaynae BoylesTELEPHONE: (916) 917-3040
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2023
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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