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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300600977
Report Date: 10/21/2024
Date Signed: 10/21/2024 03:10:41 PM


Document Has Been Signed on 10/21/2024 03:10 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:TOWN & COUNTRYFACILITY NUMBER:
300600977
ADMINISTRATOR:STEPHANIE JUKICFACILITY TYPE:
741
ADDRESS:555 E. MEMORY LANETELEPHONE:
(714) 547-7581
CITY:SANTA ANASTATE: CAZIP CODE:
92706
CAPACITY:328CENSUS: 161DATE:
10/21/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Sara Modugno, AdministratorTIME COMPLETED:
03:30 PM
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) Rose Ruppert conducted an unannounced case management visit at 1:30 PM to follow up on an email received by the Centralized Complaint and Information Bureau (CCIB) on October 14, 2024. LPA was greeted and granted entry into the facility by the Concierge and met with Sara Modugno, Administrator (AD).

The purpose of the visit is to verify there is an Administrator at the facility since the Administrator on-file no longer worked with this facility as of February 19, 2024 per Human Resources. Upon interview with current Administrator, who spoke with Chief Executive Officer (CEO) Robert Goerzen via phone, CEO recollects handing the paperwork and speaking to LPA Andrea Mendivil in February 2024 to add Gina Kolb as the Administrator. During this time the facility completed paperwork for a change of capacity but not a change of administrator. Upon review of our database, LPA Ruppert could not corroborate this since there was no supporting documentation that LPA Mendivil visited between January to March 2024. Facility will search their files for the paperwork regarding a change of administrator in February 2024.

LPA obtained and reviewed a new and signed LIC 200 form to change the Administrator to Sara Modugno and was given a copy of the Administrator's certificate which expires on September 2, 2026.

The following deficiency is being cited per Title 22 Division 6 of the California Code of Regulations.
An exit interview was conducted with Sara Modugno, Administrator and a copy of this report was given to the facility along with a copy of the LIC 809-D and Appeal Rights.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: RoseMarie RuppertTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2024
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 2


Document Has Been Signed on 10/21/2024 03:10 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: TOWN & COUNTRY
FACILITY NUMBER: 300600977

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/22/2024
Section Cited
CCR
87407(k)

1
2
3
4
5
6
7

Administrator Recertification Requirements. Whenever a certified administrator assumes or relinquishes responsibility for administering a residential care facility for the elderly, he or she shall provide written notice, within thirty (30) days, to: (1)The local licensing
1
2
3
4
5
6
7

Administrator printed and submitted a new and signed LIC 200 to change the Administrator directly to LPA. AD will follow-up with ACS.
8
9
10
11
12
13
14
office...and (2) The Department's Administrator Certification Section (ACS). Based on LPA file review and interviews the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to all persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: RoseMarie RuppertTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2