306006152-6-28-2022-22-AS-ETAA-CFTU6G-20220628151819

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006152
Report Date: 06/28/2022
Date Signed: 06/28/2022 03:18:37 PM

Document Has Been Signed on 06/28/2022 03:18 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:	COUNTRY GARDENS TERRACE, INC.		FACILITY NUMBER:	306006152
ADMINISTRATOR:	CATACUTAN, JEAN		FACILITY TYPE:	740
ADDRESS:	1103 SALVADOR STREET		TELEPHONE:	(714) 557-0515
CITY:	COSTA MESA	STATE: CA	ZIP CODE:	92626
CAPACITY:	6	CENSUS: 6	DATE:	06/28/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Jean Catacutan,Jacqueline Dizon		TIME COMPLETED:	03:30 PM

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Licensing Program Analysts (LPAs) Edward Tapia, Patricia Velazquez and Jessica Cho conducted an announced Pre-Licensing visit with Component III Orientation at The Country Gardens Terrace, Inc. LPAs Tapia, Velazquez and Cho conducted the visit with Administrator Jean Catacutan and Licensee Jacqueline Dizon . An initial application to operate a Residential Care Facility for the Elderly (RCFE) was submitted to the Central Applications Bureau (CAB) on 02/28/2022 for a capacity of 6 non-ambulatory residents.

LPAs Tapia, Velazquez and Cho along with Administrator Catacutan and Licensee Dizon observed the following:

Structure:
Facility is a one story building with 6 resident bedrooms and 1 staff room, 6 bathrooms, dining room, living room which doubles as an activity room, kitchen and 2 car garage. The facility has a dark brown stucco exterior with a latched fence and optional seating in the front yard. There is a courtyard in the backyard with a fountain outside with shading and seating for residents.

Bedrooms Residents :
All bedrooms accommodate non-ambulatory residents. Emergency lighting was present in the facility. The resident bedrooms accommodate the residents' required furnishings.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2022

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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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: COUNTRY GARDENS TERRACE, INC.	FACILITY NUMBER: 306006152
	VISIT DATE: 06/28/2022

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Bathrooms:
All bathrooms have a working toilet and wash basin. Four of the bathrooms have a walk-in shower. Two bathrooms have a shower/tub combination. Grab bars were secure and a non-skid mat was in place.
Linens and Hygiene Supplies:
Adequate supply of linens and hygiene supplies were located in a linen cabinet in a hallway as well as the resident rooms.
Appliances: Refrigerator, freezer, dishwasher, washer and dryer, microwave and electric stove top.
Emergency Phone Numbers, Exit Plan:
Posted in the dining area of the facility and readily available for review.
Postings:
The Complaint poster was posted in the entry area of the facility. Coronavirus (COVID-19) postings were observed posted throughout the facility.
Food Service and Menu:
There was an adequate supply of 7 day non-perishable and 2 day perishables present in the facility. The sample menu was available for review. The emergency food supply was inadequate for 6 residents.
Smoke and Carbon Monoxide Detectors:
Smoke detector and Carbon Monoxide alert systems were interconnected tested and found to be operational.
Fire Extinguisher:
Fully charged and were mounted on the walls throughout the facility.
Fire Clearance:
Approved on 04/18/2022 for 6 non-ambulatory residents.
Toxins and Sharps:
The cleaning supplies and knifes were locked and stored in a cabinet underneath the kitchen sink.
Water Temperature:
Tested and recorded in 6 resident bathrooms and ranged between 103.1 - 109.7 degrees Fahrenheit.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2022

LIC809 (FAS) - (06/04)

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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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: COUNTRY GARDENS TERRACE, INC.	FACILITY NUMBER: 306006152
	VISIT DATE: 06/28/2022

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Medications, First Aid Kit & Manual:
The facility has 2 First Aid kits which were checked and found to be in order. One First Aid kit is located in the medication room and the other is located in the office. The facility was missing a First Aid manual. Medication is stored in a locked cabinet located in the medication room.

Resident and Staff Files: Resident and staff records are stored in the office.

Reading Material, Games, Equipment, & Materials:

The facility had materials, games, and equipment present in the facility that commensurate with their plan of operation.

Component III:
Conducted at the Pre-Licensing visit, information was provided about how to operate the facility within compliance.

The following items need to be addressed prior to licensure:

· Obtain chairs for the resident rooms

· Obtain a First Aid manual
· Obtain lamps for the resident rooms
·

Facility does not appear ready for licensure. Any items noted during today’s visit are to be corrected by June 14, 2022. LPA Velazquez will conduct a subsequent Pre-Licensing visit on June 14, 2022 to review the items listed above. An exit interview was conducted with Administrator Aurelia Olais and Licensee Diluvan Hassan a copy of this report was provided at the time of this visit.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2022

LIC809 (FAS) - (06/04)

Page: 1 of 1

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: COUNTRY GARDENS TERRACE, INC.	FACILITY NUMBER: 306006152
	VISIT DATE: 06/28/2022

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Medications, First Aid Kit & Manual:
The facility has a First Aid kit which was checked and found to be in order. The First Aid kit is located in the medication section in the dining room. Medication is stored in a locked cabinet located in the medication area.

Resident and Staff Files: Resident and staff records are stored and locked in the dining area.

Reading Material, Games, Equipment, & Materials:

The following items need to be addressed prior to licensure:

Repair or replace light and light switch in the kitchen
Repair or replace latches for exit gates
Add a low profile threshold ramp
Obtain a current first aid manual
Emergency food and water supply
Obtain mattress pads for room 6
Obtain no smoking oxygen in use signs
Repair or replace left rear burner for stove-top
Remove excessive grease stains in overn and over racks

Facility does not appear ready for licensure. Any items noted during today’s visit are to be corrected by July 12, 2022. LPA Velazquez will conduct a subsequent Pre-Licensing visit on July 12, 2022 to review the items listed above. An exit interview was conducted with Administrator Jean Catacutan and Licensee Jacqueline Dizon copy of this report was provided at the time of this visit.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2022

LIC809 (FAS) - (06/04)

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