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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 315920101
Report Date: 07/08/2026
Date Signed: 07/08/2026 10:13:18 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/29/2026 and conducted by Evaluator Melissa Parks
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20260629084943
FACILITY NAME:COUNTRY LIVING SENIOR CAREFACILITY NUMBER:
315920101
ADMINISTRATOR:GROZAV, MARIAFACILITY TYPE:
740
ADDRESS:425 WISE ROADTELEPHONE:
(916) 956-8362
CITY:LINCOLNSTATE: CAZIP CODE:
95648
CAPACITY:6CENSUS: 5DATE:
07/08/2026
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Maria GrozavTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Facility staff did not provide adequate supervision, resulting in a resident eloping from the facility
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Melissa Parks arrived on Wednesday July 8, 2026 unannounced to conduct a complaint visit regarding the above allegation. LPA met with Administrator Maria and explained the purpose of the visit.

LPA interviewed the Administrator regarding the allegation. LPA learned the following: On 6/28/2026 at approximately 1 am, R1 exited from the front door of the facility and proceeded to walk down the road. R1 was returned to the facility by a neighbor who was returning home. LPA learned that the front door alarm did not alert staff that it was opened. R1 is diagnosed with Dementia with no history of wandering.

Based on the information detailed above, LPA finds the allegation to be substantiated. A finding that the allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency cited on 9099-D. Exit interview conducted. A copy of this report and appeal rights were provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Melissa Parks
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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Control Number 59-AS-20260629084943
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 LIVING SENIOR CARE
FACILITY NUMBER: 315920101
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/08/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/09/2026
Section Cited
CCR
87705(j)
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87705 Care of Persons with Dementia.
(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.
This requirement was not met as evidenced by: Based on interview conducted and
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Administrator will submit a plan to LPA regarding monitoring and replacing door alarms to ensure all are working properly at all times.
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documentation reviewed, the Licensee did not ensure that the front door had an audible working alarm which posed an immediate health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Melissa Parks
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2026
LIC9099 (FAS) - (06/04)
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