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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045920109
Report Date: 09/10/2024
Date Signed: 09/10/2024 02:52:51 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/10/2024 02:52 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 CLUB AT THE COMMONSFACILITY NUMBER:
045920109
ADMINISTRATOR/
DIRECTOR:		FOZ, MERYLFACILITY TYPE:
775
ADDRESS:962 KOVAK CTTELEPHONE:
(530) 342-7002
CITY:CHICOSTATE: CAZIP CODE:
95973
CAPACITY: 15CENSUS: 0DATE:
09/10/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Assistant Administrator- Michael Foz TIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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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.
The administrator explained that the day program has no participants, the space is not being utilized by any residents.
No files were reviewed because this program is not being utilized.
LPA did observe the space to be clean, odor free and in good repair.
No deficiency cited as a result of todays visit.
Exit interviewed conducted.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Jaynae Boyles
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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