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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002844
Report Date: 02/04/2022
Date Signed: 02/04/2022 12:12:11 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:COUNTRY SIDE HOME CAREFACILITY NUMBER:
315002844
ADMINISTRATOR:CERVANTES, SUSANFACILITY TYPE:
740
ADDRESS:2255 CENTRAL AVETELEPHONE:
(916) 402-4199
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY:6CENSUS: DATE:
02/04/2022
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:SUSAN CERVANTESTIME COMPLETED:
12:11 PM
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COMP II by CAB successfully completed

Method: Phone Call at CAB

COMP II Participants: SUSAN CERVANTES

Facility Type: RCFE

Application Type: CHOW

Capacity: 6

Census (if any clients in care): 4

Applicant/administrator participated in COMP II at CAB telephone call with analyst at CAB. Identification of the applicant and administrator was verified by presenting photo ID via phone. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant and administrator were advised to email/fax signed LIC 809 with copy of photo ID to CAB.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:

1. Facility operation: License type, client/resident populations, and program

2. Staff qualifications and responsibilities

3. Applicant and Administrator qualifications

4. Program policy: Abuse, admission agreement, medication management, reporting incidents to CCL, restricted & prohibited conditions

5. Grievances, Complaints, Community resources

6. Physical plant, food service

7. Application document review and technical assistance: Criminal record clearance, Health screening, Fire clearance, First Aid/CPR certificate, Administrator certificate, Financial verification, Pre-licensing inspection, Compliance history, Control of property

SUPERVISOR'S NAME: Mirella QuarantaTELEPHONE: (916) 657-2025
LICENSING EVALUATOR NAME: Gina BaldwinTELEPHONE: (916) 651-7817
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2022
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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