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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045002440
Report Date: 05/28/2025
Date Signed: 05/28/2025 01:06:00 PM

Document Has Been Signed on 05/28/2025 01:06 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:COUNTRY CREST ASSISTED LIVINGFACILITY NUMBER:
045002440
ADMINISTRATOR/
DIRECTOR:		DAVIS, IRENEFACILITY TYPE:
740
ADDRESS:55 CONCORDIA LNTELEPHONE:
(530) 533-7857
CITY:OROVILLESTATE: CAZIP CODE:
95966
CAPACITY: 150TOTAL ENROLLED CHILDREN: 0CENSUS: DATE:
05/28/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Irene Davis - administratorTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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05/28/2025 12:00 PM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with Executive Director Irene Davis. Today’s visit is regarding two incident reports that were submitted to licensing regarding incidents that occurred on 04/15/2025 and 05/22/2025. Both of these incidents resulted in residents sustaining fractures related to falls that occurred in the facility.

On 04/15/2025 Resident 1 (R1) pushed their PHB was complaining of left hip pain and wanted to go to the hospital to be checked out and get x rays. EMS was called and resident was transported to local hospital for evaluation. R1 was admitted to hospital with a diagnosis of hip pain and a fractured sacrum.

During the investigation it was learned that on 3/04/2025 R1 was walking their dog and fell. R1 was sent out to hospital for evaluation and sent back with pain medication. On 04/07/2025 R1 had bruising due to an unwitnessed fall and was sent out again with no findings. On 04/15/2025 R1 had unmanaged pain and was sent out to the hospital, and was diagnosed with fractured sacrum. R1 was still experiencing pain so the facility sent R1 back to the hospital and they were discharged with stronger pain meds, home health, and physical therapy referral.

Continued on LIC809-C

Lauren CrockerTELEPHONE: (916) 261-4966
Rebecca KnightTELEPHONE: (530) 356-2841
DATE: 05/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/28/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: COUNTRY CREST ASSISTED LIVING
FACILITY NUMBER: 045002440
VISIT DATE: 05/28/2025
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On 05/22/2025 Resident 2 (R2) pushed their pendant and when staff arrived they found R2 on the floor in their bathroom. R2 stated they were attempting to transfer themselves and fell. R2 was assessed for injury and was found to have two skin tears on their left hand. R2 complained left hip pain and left knee pain. EMS was called and R2 was transported to hospital for evaluation and subsequently admitted with diagnosis of left hip fracture.

During the investigation it was learned that R2 normally does transfer themselves during the day. In the morning R2 is assisted by staff to get out of bed, get dressed, and brush their teeth due to being in a wheelchair. That morning R2 attempted to transfer themselves and did not lock one side of their wheelchair and subsequently fell. R2 is currently hospitalized and scheduled for surgery. It is anticipated that R2 will be transferred to skilled nursing after surgery for rehabilitation.

In order to prevent this from occurring the facility will conduct a fall prevention training with all staff. Administrator will submit a copy of the facility’s fall prevention plan to LPA.

LPA referred administrator to ​​​​​​​​​StopFalls Sacramento Coalition for additional resources in fall prevention.

https://dhs.saccounty.gov/PUB/StopFallsSacramento/Pages/Stop-Falls-Sacramento-Coalition.aspx

No deficiencies were cited as a result of today’s visit. Exit interview conducted and a copy of the report was provided to with Executive Director Irene Davis.

SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025
LIC809 (FAS) - (06/04)
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