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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002045
Report Date: 11/04/2022
Date Signed: 11/04/2022 04:45:58 PM


Document Has Been Signed on 11/04/2022 04:45 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:COUNTRY OAKS MANORFACILITY NUMBER:
347002045
ADMINISTRATOR:ALEKSANDER MOLITVENIKFACILITY TYPE:
740
ADDRESS:7595 LINDEN AVENUETELEPHONE:
(916) 792-4974
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:6CENSUS: 5DATE:
11/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Alex Molitvenik, Administrator TIME COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual.
LPA met with Alex Molitvenik, Administrator, and explained purpose of inspection. LPA observed (2) residents to be in the common areas and (3) residents to be in their rooms at the start of the inspection. Currently, there are (0) residents on hospice. The facility is licensed for (6) non-ambulatory residents. Prior to initiating today's inspection, LPA completed required COVID-19 protocols. LPA was screened per Covid-19 precautionary measures upon entering the facility, and LPA was wearing a surgical mask.

LPA and Administrator toured the interior and exterior of the facility including the common areas, (5) resident bedrooms, (2) full bathrooms, kitchen, staff room and locked laundry area. LPA observed the facility to be clean, in good repair and odor-free. LPA observed the bathrooms to have the necessary grab bars, non-skid flooring, and paper towels - Administrator agrees to post 20-second hand-washing posters at each bathroom and kitchen sink. LPA observed sufficient 2+day perishable and 7+day non-perishable supply of food. LPA observed the sharps to be unsecured in the kitchen and some medications to be unsecured in resident (R1's) room and in a cabinet near the kitchen. LPA and Administrator discussed vaccination status of residents/staff, eligibility for boosters. LPA observed a few Covid posters throughout as well as other required postings. LPA observed (1) unlocked gate from the inside back patio with covered patio seating. There are no pools or bodies of water. All exit doors have alarms. LPA reviewed (2) staff files and found them to contain current training documentation, including First Aid/CPR. All staff are fingerprint cleared/associated. LPA reviewed (3) resident files and found them to be missing care plans. LPA requested an updated copy of LIC500, LIC308, and current liability insurance be provided by 11/14/2022.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (2) deficiencies are cited on the 809-D page.

Exit interview with Administrator. Copy of report and appeal rights provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2022
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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Document Has Been Signed on 11/04/2022 04:45 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926


FACILITY NAME: COUNTRY OAKS MANOR
FACILITY NUMBER: 347002045

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as LPA observed multiple sharps to be in a drawer with a non-functioning lock, unsecured medications in resident (R1) room and in a cabinet near the kitchen, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/07/2022
Plan of Correction
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Administrator immediately removed the unlocked sharps and medications and placed them in a locked area. Administrator agrees to install a functioning lock on a kitchen drawer to store sharps in and to always store medications in a locked area with the rest of the medications. Documentation (photo) of working lock to be sent to the Department (email/fax) by 11/7/2022.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 11/04/2022 04:45 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926


FACILITY NAME: COUNTRY OAKS MANOR
FACILITY NUMBER: 347002045

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87467(a)(1)
87467 Resident Participation in Decision making (a) Prior to, or within two weeks of the resident’s admission, the licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident’s preferences regarding the services provided at the facility.

(1) At a minimum the written record shall include the date of the meeting, name of individuals who participated and their relationship to the resident, and the agreed-upon services to be provided to the resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review,, the licensee did not comply with the section cited above in (3) of (5) resident files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/21/2022
Plan of Correction
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Administrator agrees to complete a care plan (i.e. LIC625) for each resident, detailing the care/services the facility will provide. Copies of each completed care plan to be provided to the Department by fax/email by 11/21/2022.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2022
LIC809 (FAS) - (06/04)
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