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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881181
Report Date: 09/12/2022
Date Signed: 09/12/2022 10:33:28 AM

Document Has Been Signed on 09/12/2022 10:33 AM - 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:COUNTRY COMFORT #1FACILITY NUMBER:
331881181
ADMINISTRATOR:QUINLAN, GRACE DIANAFACILITY TYPE:
735
ADDRESS:49465 BLACK MOUNTAIN COURTTELEPHONE:
(951) 537-7509
CITY:AGUANGASTATE: CAZIP CODE:
92536
CAPACITY: 3CENSUS: 3DATE:
09/12/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Administrator Grace "Diana" QuinlanTIME COMPLETED:
10:40 AM
NARRATIVE
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Licensing Program Analyst (LPA) Jesse Gardner arrived unannounced to conduct a case management health and safety visit in conjunction with a repopulation of the facility.

LPA met with Administrator Diana Quinlan and explained the purpose of the visit.

There were no residents inside the facility during the visit, as they were at their day program. No imminent health and/or safety concerns were observed at the time of visit. LPA observed no health and/or safety hazards inside the facility. LPA observed all facility utilities to be on and operating without issue. There was a sufficient amount of staff present and/or available to provide care. LPA assessed the available food supply and observed that the supply meets the requirement of a two (2) day supply of perishable foods and a seven (7) day supply of non-perishable foods. Medications were found to be in sufficient supply as well.

Based on the information obtained during today's visit, there are no immediate threats to the health, safety, and welfare of the residents in care. No deficiencies were cited during today's visit.

An exit interview was conducted and a copy of this report was provided to Quinlan.

SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2022
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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