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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006152
Report Date: 07/02/2026
Date Signed: 07/02/2026 12:57:22 PM

Document Has Been Signed on 07/02/2026 12:57 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:COUNTRY GARDENS TERRACE, INC.FACILITY NUMBER:
306006152
ADMINISTRATOR/
DIRECTOR:		CATACUTAN, JEANFACILITY TYPE:
740
ADDRESS:1103 SALVADOR STREETTELEPHONE:
(714) 557-0515
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY: 6CENSUS: 5DATE:
07/02/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Designee Arjan BanezTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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On July 2, 2026, Licensing Program Analysts (LPAs) Brandon Lopez and Tran Nguyen made an unannounced visit to the facility to conduct the required annual inspection. LPAs were greeted and granted entry into the facility by staff after explaining the purpose for the visit. Administrator Mary Jean Catacutan was notified via telephone but was unable to assist with today's inspection. LPAs observed that Mary Jean Catacutan has a valid Administrator certificate which expires on August 2, 2027. Designee Arjan Banez later arrived to assist with the inspection.

The facility is a Residential Care Facility for the Elderly (RCFE) licensed for six non-ambulatory residents and has a hospice waiver for six. The facility consist of six private resident bedrooms, six bathrooms, a staff bedroom, a living room, a dining room, a kitchen, and an attached two car garage. LPAs, accompanied by the Designee, conducted a tour of the interior portions of the facility. On today's visit, there were five residents in care and two care giving staff present. LPAs observed the See Something, Say Something poster (PUB 475) mounted on the wall by the entryway of the facility. LPAs inspected the six private resident bedrooms and observed them to be clear of any hazards. LPAs observed resident bedrooms to have the required furnishings of a bed, a chair, a chest of drawers, and a lamp. LPAs observed resident beds to have clean linens and blankets. LPAs observed additional linens to be stored in a hallway closet. LPAs inspected the six bathrooms and observed them to be clean. Resident bathrooms were equipped with grab bars and non-skid floor mats. Faucets and toilets were operational. Hot water temperature measured between 111 and 116.7 degrees Fahrenheit. LPAs observed the staff bedroom to be free of any hazards.

LPAs observed the facility has a two day perishable and a seven day non-perishable food supply in the kitchen. LPA observed kitchen knives and sharps to be stored in a locked kitchen cabinet.
CONTINUED ON LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Brandon Lopez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/02/2026
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 5
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: COUNTRY GARDENS TERRACE, INC.
FACILITY NUMBER: 306006152
VISIT DATE: 07/02/2026
NARRATIVE
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LPAs observed a fire extinguisher to be in the kitchen and it was observed to be charged and up to date on service. LPAs tested the wired smoke detectors and individual carbon monoxide detector which tested operational. LPAs observed the facility did not conduct an emergency disaster drill in the last quarter as required. LPAs observed the facility conducted their last emergency disaster drill on January 7, 2026. LPAs observed the centrally stored medication to be kept in a locked cabinet located in the kitchen. LPAs observed a first aid kit to be stored in the kitchen. LPAs observed the facility did not have an approved first aid manual on hand at the facility. LPAs observed the door leading to the attached two car garage to be kept locked and inaccessible to residents in care. LPAs observed the garage to be used for storage and laundry. LPAs observed chemicals and toxins to be stored in a locked cabinet located in the garage. LPA observed the facility has a three day emergency food and water supply stored in the garage.

LPAs, accompanied by the Designee, conducted a tour of the exterior portions of the facility. LPAs observed the exterior to be clear of any obstructions or hazards. LPAs observed a shaded outdoor seating area with furniture for resident use. LPAs observed the perimeter gates of the facility to be self-latching and can be opened in an evacuation. There are no bodies of water on the premises.

LPAs reviewed all five resident files. LPAs observed that Resident #2 (R2) Medical Assessment dated April 9, 2026, states that R2 is bedridden. During the visit, LPAs met with R2 and confirmed that R2 is bedridden due to R2 being unable to reposition herself on her own. Staff present during the visit confirmed that R2 is no longer able to reposition herself on her own and relies on the assistance from staff to be repositioned. Based on the facility current fire clearance, they are not allowed to retain a resident who is bedridden. During the file review, LPAs also observed that Resident #3 (R3) currently has a gastrostomy tube. Under California Code of Regulation Section 87615, a gastrostomy tube is considered a prohibited health condition. Under California Code of Regulation Section 87633, a facility is only allowed to retain a resident with a prohibited health condition if they are actively receiving hospice services. During the file review, LPAs confirmed that R3 is currently not receiving hospice services. During the visit, LPAs observed and verified that R3 currently has a gastrostomy tube in place. LPAs reviewed the residents' medication and medication administration records. LPAs reviewed three staff files. All staff are background cleared and associated to the facility.

Based on the observations made during today's visit, deficiencies are being cited on the attached LIC809-D pages. An immediate civil penalty will also be assessed in the amount of $500.00 for a fire clearance violation. An exit interview was conducted with Designee Arjan Banez. A copy of the report and appeal rights were provided at time of visit.
NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Brandon Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/02/2026 12:57 PM - It Cannot Be Edited


Created By: Brandon Lopez On 07/02/2026 at 12:29 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: COUNTRY GARDENS TERRACE, INC.
FACILITY NUMBER: 306006152

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/02/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPAs observed that Resident #2 (R2) Medical Assessment dated April 9, 2026, states that R2 is bedridden and confirmed that R2 is bedridden due to R2 being unable to reposition herself on her own. The facility's fire clearance does not allow them to retain a bedridden resident.
POC Due Date: 07/03/2026
Plan of Correction
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The Designee stated that the facility will submit a request to update their fire clearance to allow them to retain a bedridden resident. The Designee stated that he will provide LPA a written request, an updated LIC200, and an updated facility sketch, via email or fax by POC due date,
Type A
Section Cited
CCR
87615(a)
Prohibited Health Conditions
(a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. During a file review, LPAs observed that Resident #3 (R3) currently had a gastrostomy tube. LPAs also observed that R3 is currently not receiving hospice services. During the visit, LPAs observed and verified that R3 currently has a gastrostomy tube in place.
POC Due Date: 07/03/2026
Plan of Correction
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The Designee stated that the facility will submit an exception request for the resident requesting for the facility to retain the resident with a prohibited health condition. The Designee stated that he will provide LPA the written request via email or fax by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Sheila Santos
NAME OF LICENSING PROGRAM MANAGER:
Brandon Lopez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/02/2026 12:57 PM - It Cannot Be Edited


Created By: Brandon Lopez On 07/02/2026 at 12:29 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: COUNTRY GARDENS TERRACE, INC.
FACILITY NUMBER: 306006152

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/02/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. LPAs observed the facility did not conduct an emergency disaster drill last quarter. LPAs observed the facility conducted their last emergency disaster drill on January 7, 2026.
POC Due Date: 07/13/2026
Plan of Correction
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The Designee stated that he will conduct an emergency disaster drill with all facility staff. The Designee agreed to provide LPA proof of the disaster drill training via email or fax by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Sheila Santos
NAME OF LICENSING PROGRAM MANAGER:
Brandon Lopez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2026


LIC809 (FAS) - (06/04)
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