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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700902
Report Date: 03/12/2025
Date Signed: 03/12/2025 12:13:55 PM

Document Has Been Signed on 03/12/2025 12:13 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/
DIRECTOR:		LETICIA FERMOSO HIGARESFACILITY TYPE:
740
ADDRESS:2005 IRON POINT RDTELEPHONE:
(916) 836-8022
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY: 60CENSUS: 42DATE:
03/12/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:ED Katherine MartinezTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Lavinia Muscan arrived on March 12, 2025 to conduct the annual inspection.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed five resident (5) and five staff (5) files. All residents files contained the required paperwork. All staff files contained the required paperwork and training.

LPA and ED Katherine Martinez 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, and memory care common areas. Water temperatures in the apartments toured were within the required range of temperature. 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.

Exit interview conducted. A copy of this report was printed and given to ED.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Lavinia Muscan
LICENSING EVALUATOR SIGNATURE: DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/12/2025
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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