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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006152
Report Date: 07/12/2022
Date Signed: 07/12/2022 12:37:24 PM

Document Has Been Signed on 07/12/2022 12:37 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, JEANFACILITY TYPE:
740
ADDRESS:1103 SALVADOR STREETTELEPHONE:
(714) 557-0515
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY: 6CENSUS: 6DATE:
07/12/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
11:57 AM
MET WITH:Jean Catacutan - AdministratorTIME COMPLETED:
12:50 PM
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Licensing Program Analyst (LPA) Patricia Velazquez conducted an announced visit to Country Gardens Terrace, Inc. LPA Velazquez was allowed entry into the facility and met with Administrator Jean Catacutan. The purpose of today's subsequent Pre-Licensing visit was to follow-up on the issues that were present during the initial Pre-Licensing visit dated 06/28/2022. The following issues were observed and required correction:
  • 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 the stove-top
  • Remove excessive grease stains in oven and oven racks




On today's visit the aforementioned items have been addressed and corrected. The aforementioned items reviewed during this visit are in compliance. The Pre-Licensing is now complete. The license will be granted upon completion of a final review and approval from the Licensing Program Manager and the Central Applications Bureau. An exit interview was conducted with Administrator Jean Catacutan and a copy of this report was provided at the time of this visit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2022
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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