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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300600977
Report Date: 10/27/2023
Date Signed: 10/27/2023 01:43:17 PM


Document Has Been Signed on 10/27/2023 01:43 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
CCLD Regional Office, 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: 191DATE:
10/27/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:34 PM
MET WITH:Rob Goerzen- CEO/PresidentTIME COMPLETED:
02:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jessica Cho continued the visit after delivering the findings into Complaint Control Number: 22-AS-20230719155923. The purpose of this subsequent visit is to issue a citation after discovering a deficiency while conducting an investigation in connection with the complaint mentioned above. LPA explained the reason for the Case Management-Deficiencies visit to Chief Executive Officer/President Rob Goerzen.

During the complaint investigation held on August 31, 2023, Staff #1 (S1) confirmed that the facility did not report the fire caused by an electrical circuit from the steam well due to being deemed uneventful. The fire occurred on July 18, 2023, and as per the Title 22 regulations, the facility is mandated to report a fire to the licensing agency no later than the next working day. The Department did not receive the incident report the following day after the occurrence, therefore the preponderance of evidence standard has been met.

A deficiency is being cited as per Title 22, Division 6, Chapter 8 of the California Code of Regulations. See the attached LIC809-D.

An exit interview was conducted with Chief Executive Officer/President Rob Goerzen, and a copy of this report along with the LIC809-D, LIC811, and the appeal rights were provided at the end of the visit.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2023
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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Document Has Been Signed on 10/27/2023 01:43 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: TOWN & COUNTRY
FACILITY NUMBER: 300600977

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/03/2023
Section Cited
CCR
87211(a)(3)

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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require... (3) Fires or explosions which occur in or on the premises shall be reported immediately to the local fire authority…; and no later than the next working day to the licensing agency.
This requirement was not met as evidenced by:
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CEO/President stated that they will submit the incident report pertaining to the fire that occurred on 07/18/23, develop procedures to delegate responsibilities for timely report completion, and to provide proof of the procedures to LPA via email by POC due date.
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Based on LPA’s review of the record and through S1’s admission, S1 did not report the fire to the Department within the next business day which poses a potential Health, Safety, and Personal Rights risk to persons 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: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2023
LIC809 (FAS) - (06/04)
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