045920038-9-10-2024-59-AS-JBOS-D8YQKK-20240910121428

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 045920038
Report Date: 09/10/2024
Date Signed: 09/10/2024 12:15:25 PM

Document Has Been Signed on 09/10/2024 12:15 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 HOUSE		FACILITY NUMBER:	045920038
ADMINISTRATOR:	FOZ, MERYL		FACILITY TYPE:	740
ADDRESS:	966 KOVAK CT		TELEPHONE:	(530) 342-7002
CITY:	CHICO	STATE: CA	ZIP CODE:	95973
CAPACITY:	20	CENSUS: 18	DATE:	09/10/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:20 AM
MET WITH:	Assistant Administrator- Michael Foz		TIME COMPLETED:	12:20 PM

NARRATIVE

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On 09/10/2024, Licensing Program Analyst (LPA) Jaynae Boyles, arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA met with Facility Assistant Administrator, Michael Foz and explained the purpose of the visit.

LPA Boyles 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, backyard, shed, and common restrooms. LPA observed the resident bedrooms to have all the required furnishings, working lights/fans with windows with screens. All resident bathrooms observed to be in working order and have the required supplies. LPA observed the resident showers to have bathroom the necessary grab bars, non-skid flooring or shower chair, paper towels, trash can with lids and 20-second hand-washing poster. Hot water was measured throughout the facility, the temperature was above the required temperature (122 F) on one side of the building and below the required temperature(101 F) on the other side of the building. The thermostat was within range in the facility but inconsistent throughout the facility, some rooms and halls were warmer on one side.

Facility has a 2-day perishable and a 7-day non-perishable amount of food. LPA observed medications sharps to be locked inaccessible to residents. LPA observed posted weekly menu and activities for the residents. LPA observed a plethora of supplies for the residents to use.

LPA observed fire extinguishers, fire detectors, and carbon monoxide detectors. LPA observed a complete first aid kit ready for emergency use. LPA observed a completed emergency disaster plan, and the required emergency disaster drills conducted within the last 12 months.

LPA observed the facility to be clean, in good repair and odor-free. In the areas toured no immediate health, safety, or personal rights violations were observed.

LPA reviewed a total of five (5) residents' files and five (5 ) staff files. Two of the five resident files reviewed had outdated physician reports for residents who have dementia. Employee files contained all of the required documentation.

The following deficiencies were cited per Title 22 of the California Code of Regulation (See LIC 809D). Appeal Rights were explained and provided to the facility representative listed above Exit interview conducted.

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Jaynae Boyles	TELEPHONE: (916) 208-6251
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024

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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Document Has Been Signed on 09/10/2024 12:15 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: COUNTRY HOUSE	FACILITY NUMBER: 045920038
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(e)(3)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that the water is not consistently measuring within range throughout the facility which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/24/2024
	Plan of Correction
1 2 3 4	Administrator will ensure that caregivers are check the water temp before resident showers. The administrator will enusre that the water temp remains in range. Admin will provide a training to the caregivers, and provide documentation to the department. Administrator will monitor the temps to determin if the facility needs new water heater.

Type B

Section Cited

CCR

87705(c)(5)

Care of Persons with Dementia

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in two out of five resident files did not have an updated medical assessment which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/24/2024
	Plan of Correction
1 2 3 4	The Admin and RCC will work together to create and implement a tracking system for residents with dementia to ensure that residents with dementia recieve a medical assessment annually.

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 Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Jaynae Boyles	TELEPHONE: (916) 208-6251
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024

LIC809 (FAS) - (06/04)

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