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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700902
Report Date: 03/06/2024
Date Signed: 03/06/2024 12:47:53 PM


Document Has Been Signed on 03/06/2024 12:47 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:FOLSOM COUNTRYHOUSEFACILITY NUMBER:
342700902
ADMINISTRATOR:LETICIA FERMOSO HIGARESFACILITY TYPE:
740
ADDRESS:2005 IRON POINT RDTELEPHONE:
(916) 836-8022
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY:60CENSUS: 42DATE:
03/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Director of Nursing Brian PawloskiTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Lavinia Muscan arrived on 3/6/24 to conduct the annual inspection.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed resident (10) and staff (9) files. All resident files contained the required paperwork. All staff files contained the required paperwork and training.

LPA and Director of Nursing Brian Pawloski toured the facility together to ensure the health and safety of residents in care. The areas toured included, kitchen, hallways, memory care apartments, memory care dining room/kitchen, and memory care common areas. Food is within compliance. Water temperature is within the required range of temperature. Fire drills reviewed. In the areas toured, there were no health or safety violations observed.

LPA requested a copy of the LIC 500, LIC610E and current liability insurance to be sent to the Department by end of the month.

No deficiencies cited. Exit interview conducted. A copy of this report was left at the facility.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia MuscanTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2024
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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