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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700902
Report Date: 08/03/2021
Date Signed: 08/11/2021 03:06:37 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:FOLSOM COUNTRYHOUSEFACILITY NUMBER:
342700902
ADMINISTRATOR:LOPEZ, JANELLEFACILITY TYPE:
740
ADDRESS:2005 IRON POINT RDTELEPHONE:
(916) 836-8022
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY:60CENSUS: 14DATE:
08/03/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Jennifer Scarberry (Administrator)TIME COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Konnor Leitzell arrived at facility to conduct a Case Management Visit. Community Care Licensing (CCL) received an Incident Report (LIC 624) and Report or Suspected Dependent Adult/Elder Abuse (SOC 341) from facility regarding Resident's recent trip to the ER. Prior to initiating the case manage inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA contacted Admin and completed a facility risk assessment, and was sure to apply hand sanitizer prior to entry. Upon entry, LPA was screened and greeted by Ashley Steele (Admin Assistant). LPA then explained the purpose for the visit to admin.

During visit, LPA conducted interviews with Jennifer Scarberry (Admin); Officer Limon (Folsom County Police); Staff 1; Staff 2; Staff 3; and Resident. Interviews documented on LIC812's. LPA toured the dining area, kitchen, and Resident's personal room.LPA is requesting the following documents to be submitted to CCL via email at konnor.leitzell@dss.ca.gov or via fax at (916) 263-4744 by COB 8/13/2021: Residents Admission Agreement; LIC602; Charting Notes from move in to current; and discharge papers from recent hospital visits.

No deficiencies are being cited as a result of today’s visit.

Exit interview conducted and report left at facility.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Konnor LeitzellTELEPHONE: (916) 708-9618
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021
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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