306006428-2-14-2024-22-AS-CGUZ-D2FV4U-20240214150655

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006428
Report Date: 02/14/2024
Date Signed: 02/14/2024 03:07:54 PM

Document Has Been Signed on 02/14/2024 03:07 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 CLUB SENIOR HOME CARE		FACILITY NUMBER:	306006428
ADMINISTRATOR:	ABUDA, MA TERESA		FACILITY TYPE:	740
ADDRESS:	8271 COUNTRY CLUB DRIVE		TELEPHONE:	(909) 900-6064
CITY:	BUENA PARK	STATE: CA	ZIP CODE:	90621
CAPACITY:	6	CENSUS: 0	DATE:	02/14/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Ma Teresa Abuda, Gary Tadea, Peppi Pala, Heidi Tadeo, Kian Pascual		TIME COMPLETED:	03:20 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) Claudia Gutierrez made an announced visit to the facility for purpose of conducting a pre-licensing inspection. LPA met with designated Administrator (AD) Ma Teresa Abuda, Licensee Gary Tadeo and Peppi Pala, Assistant Administrator (AAD) Heidi Tadeo and Consultant Kian Pascual. An application to operate an Residential Care Facility for the elderly (RCFE) for (6) capacity, (0) ambulatory, (0) non-ambulatory, and (6) bedridden residents was received by CCL on 9/20/2023. Structure: The facility is a one-story house with six resident bedrooms, one staff bedroom, two full size bathrooms, six half bathrooms, a living room, a kitchen, a dining room, an activity room/staff office, a laundry room, and attached two car garage. LPA observed the See Something, Say Something poster (PUB 475) in the facility mounted on the wall in the entranceway. There is a backyard with an exit gate each on one side of the house. There is a shaded seating area and LPA did not observe any obstacles or hazards in the backyard. Resident Bedrooms All resident bedrooms had the required furnishings. LPA observed all beds had linens and blankets. Signal system There is no signal system. Toxins: All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residents and will be stored and locked in the laundry room. Pool/Jacuzzi: No bodies of water were observed.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia Gutierrez	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024

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 CLUB SENIOR HOME CARE	FACILITY NUMBER: 306006428
	VISIT DATE: 02/14/2024

NARRATIVE

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Medications, First-Aid Kit & Book:
Medication will be stored in a locked medicine cart. First aid kit is stored in the staff office. The first aid kit has all the required elements.

Resident & Staff Files:
Records will be kept in a locked file cabinet.

Fire Extinguisher:
Fire extinguisher is fully charged with service tag dated 9/26/2023.

Reading Material, Games, Equipment & Materials:
The facility has reading books, activity books, arts and crafts supplies, board games, puzzles, and other recreational materials for resident use stored in the activity room.

Fire clearance:
Was approved by a fire inspector of Orange County Fire Authority on 11/07/2023. Special conditions noted, “Bedrooms #3-7 approved for bedridden clients.”

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

Bedrooms Staff:
There is one staff bedroom.

Bathrooms:
All bathrooms have working plumbing. Hot water measured between 115.8- and 118.9-degrees Fahrenheit.

Linens & Hygiene Supplies:
A supply of extra linen was stored in the closet of each resident bedroom.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia Gutierrez	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024

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 CLUB SENIOR HOME CARE	FACILITY NUMBER: 306006428
	VISIT DATE: 02/14/2024

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Emergency Phone Numbers, Exit Plan & Menu:
Posted and available, means of exiting, and emergency phone numbers. Food menu is posted and available.

Food Service:
A supply of 2-day perishable and 7-day of non-perishable food was observed and will be maintained on hand.

Smoke Detectors:
Smoke detectors and carbon monoxide detectors tested operational.

Appliances:
Gas burner stove, dishwasher, refrigerator, microwave, washer, and dryer are operational.

Licensees and designated AD was notified that the final application approval will be issued by the Centralized Applications Bureau in Sacramento. An exit interview was conducted and a copy of this report was provided to Licensee.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia Gutierrez	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024

LIC809 (FAS) - (06/04)

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