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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 097000124
Report Date: 08/29/2023
Date Signed: 08/29/2023 11:56:17 AM


Document Has Been Signed on 08/29/2023 11:56 AM - 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:APPLE COUNTRY CARE HOMEFACILITY NUMBER:
097000124
ADMINISTRATOR:FOSS, LAURAFACILITY TYPE:
740
ADDRESS:4330 HARNESS TRACTTELEPHONE:
(530) 644-3026
CITY:CAMINOSTATE: CAZIP CODE:
95709
CAPACITY:7CENSUS: 4DATE:
08/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Mary Hensley Administrator TIME COMPLETED:
12:19 PM
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On 08/29/2023 10:00 AM Licensing Program Analyst (LPA) Sarah Benson and Licensing Program Analyst Lavinina Muscan arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with Administrator Mary Hensley (cert #6020936740 exp.10-22-24) and explained the purpose of the visit.

LPA's and administrator toured the facility together to ensure the health and safety of residents in care. Areas toured include but are not limited to six (6) resident rooms, common areas, three (3) bathrooms, kitchen, storage areas and back yard. In the areas toured no immediate health, safety, or personal rights violations were observed. Staff and resident files were reviewed. Medications were also reviewed.



Common area was clean and in good repair. All bedrooms had required furniture, bedding, and lighting. Bathrooms were clean and in good repair. Kitchen was clean and in good repair. Cooking/dining equipment and utensils were present Facility has required (7) seven-day non-perishable and (2) day perishable supply of food. Medication is locked in a locked closet.

Administrator certificate is current. First aid kit fully stocked and ready for emergency use. Fire extinguisher fully charged. Smoke detectors are all operational. All employees requiring background checks are cleared. All required postings are displayed within facility.

No pools/bodies of water are on premises. No firearms are on premises. Last disaster drill was conducted August 15 2023, the facility has been conducting drills every 3 months.

The facility is in compliance. No deficiencies are being cited as a result of today’s inspection.



Exit interview conducted and copy of report was provided to administrator.
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Sarah BensonTELEPHONE: 530-895-5033
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2023
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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