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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045920109
Report Date: 03/11/2025
Date Signed: 03/11/2025 03:09:08 PM

Document Has Been Signed on 03/11/2025 03:09 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:
03/11/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:05 PM
MET WITH:Michael Foz AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:20 PM
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03/11/2025 at 02:15 PM Licensing Program Analyst (LPA) Sarah Benson arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with Michael Foz Administrator and explained the purpose of the visit. The Administrator reported there are no residents using the facility at this time.

LPA Benson and administrator toured the facility together to ensure the health and safety of residents. The facility has taken appropriate measures to protect the clients from hazards. Areas toured include but are not limited to classroom, common areas, bathroom, storage areas and yard. In the areas toured no immediate health, safety, or personal rights violations were observed.


The common area was clean, odor-free and in good repair. The bathroom was clean and in good repair.

The facility was observed to be at a comfortable temperature. Fire extinguisher fully charged. Carbon monoxide and smoke detectors are all operational. Hot water temperature measured within required Title 22 regulations of 105 degrees F and 120 degrees F. All required postings are displayed within the facility.

No pools/bodies of water are on the premises. No firearms are on premises.

The facility is in compliance. No deficiencies are being cited as a result of today’s inspection.



Exit interview conducted and copy of report was provided to administrator.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sarah Benson
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2025
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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