<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405800509
Report Date: 05/03/2021
Date Signed: 05/03/2021 10:36:08 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: 0DATE:
05/03/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Licensee Laura WillisonTIME COMPLETED:
10:35 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) De Leon conducted a Case Management Closure 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 Facetime with the Licensee Laura Willison at 10:00am. LPA explained the purpose of the visit.

Licensee took LPA on a virtual tour of the full physical plant. The facility has no residents, all 5 residents have been relocated to other Assisted Living Community Care Licensing (CCL) facilities. The information on the relocation of residents and the facility license has been mailed to CCL. A cleaning crew was present cleaning out the facility. All residents belongings were gone and no residents are currently residing at the facility. No staff present. The facility looked empty and is no longer operating. The facility file will be closed.

Exit interview conducted and copy of report will be emailed to the Licensee for signature and return to CCL.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1