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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405800509
Report Date: 11/05/2020
Date Signed: 11/05/2020 10:37:11 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:COUNTRY LIVIN SENIOR HOMEFACILITY NUMBER:
405800509
ADMINISTRATOR:LAURA WILLISONFACILITY TYPE:
740
ADDRESS:4930 SYCAMORE ROADTELEPHONE:
(805) 461-5306
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY:8CENSUS: 5DATE:
11/05/2020
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Laura Willison, LicenseeTIME COMPLETED:
10:23 AM
NARRATIVE
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Licensing Program Analyst (LPA) De Leon conducted a Case Management visit to the facility above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s visit was conducted by Telephonic video with the Licensee Laura Willison at 10:00am. LPA explained the purpose of the visit. Entrance interview conducted.

On 11/02/2020, a credible witness (CW1) visited the facility and observed Staff 1 (S1) in the facility not wearing a mask. According to the credible witness, the staff was in the living room with four residents present. The licensee failed to protect the personal rights of residents in care to be able to receive safe and healthful accommodations, in that the facility staff (S1) failed to wear face coverings while providing care and supervision to residents in care. The licensee also allowed two construction workers to work inside the home without wearing face coverings. This is a violation of official government orders requiring the wearing of face coverings while working under specified conditions.

Pursuant to Title 22, California Code of Regulations, the deficiency will be cited on 809-D.

Exit interview conducted, deficiency cited, a copy of this report and appeal rights emailed to Licensee for signature and return.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2020
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: COUNTRY LIVIN SENIOR HOME
FACILITY NUMBER: 405800509
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/05/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
11/12/2020
Section Cited

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...To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by:
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Based on CW1 statement the licensee failed to ensure S1 and construction workers were wearing face coverings which poses an immediate health, safety and personal rights 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.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:
DATE: 11/05/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/05/2020
LIC809 (FAS) - (06/04)
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