331881181-9-14-2023-18-AS-JROO-CVNPWA-20230914114026

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881181
Report Date: 09/14/2023
Date Signed: 09/14/2023 11:40:32 AM

Document Has Been Signed on 09/14/2023 11:40 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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	COUNTRY COMFORT #1		FACILITY NUMBER:	331881181
ADMINISTRATOR:	QUINLAN, GRACE DIANA		FACILITY TYPE:	735
ADDRESS:	49465 BLACK MOUNTAIN COURT		TELEPHONE:	(951) 537-7509
CITY:	AGUANGA	STATE: CA	ZIP CODE:	92536
CAPACITY: 3		CENSUS: 2	DATE:	09/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Licensee Grace Diana Quinlan		TIME COMPLETED:	11:45 AM

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On 9/14/2023, Licensing Program Analyst (LPA) Janette Romero arrived unannounced at the facility to conduct an annual required visit. LPA was greeted and granted entry by Licensee, Grace Diana Quinlan. The administrator certficate for Licensee Quinlan expires on 4/11/2024. During the visit, Licensee Quinlan and one (1) client were present and LPA was informed that one (1) client was at day program.

The facility is approved to care for three (3) ambulatory clients and serves adults ages 18-59. LPA toured the facility's interior and exterior with Licensee Quinlan. During the visit, LPA observed the following:

Kitchen: LPA toured the kitchen and observed kitchen to be clean. Food is stored in a safe and healthful manner. LPA observed food supply met the requirement for a 2-day supply of perishable food items and 7-day of non-perishable food items. Knives/sharps, cleaning solutions and chemicals are secured in a locked cabinet under the kitchen sink.

Dining and Living room: LPA toured the dining and living/family room area. LPA observed area to be clean and furniture in good condition. Activities and board games are available for the clients. Fire extinguisher is charged and mounted near the living room.

Hallway: LPA toured the hallway and observed hallway to be clean with no pathway obstruction. Carbon monoxide and smoke detector were tested and functioning properly.

Continued on LIC809-C..

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023

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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: COUNTRY COMFORT #1	FACILITY NUMBER: 331881181
	VISIT DATE: 09/14/2023

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Continued from LIC809.

Centrally Stored Medications: LPA observed a first aid kit with required components. Medications were secured in a cabinet near the laundry room. LPA reviewed physical medications for the clients as well as the Medication Administration Record (MAR) used to log administration of clients’ medications. No discrepancies discovered.

Bedrooms: Client bedrooms were each furnished with a bed, chair, closet, clothing storage and lighting.

Bathrooms: Bathrooms have a working toilet, wash basin, and were equipped with a grab bar in the shower. The hot water temperature measured at 108-degrees Fahrenheit. The facility has clean towels, blankets, and linen, available in different colors for the clients in care.

Laundry/Garage: LPA toured the laundry room and garage. Washing machine and dryer are in good repair. Emergency food supplies and water are stored in the garage.

Yard/Outside Area: Covered patio seating is available for clients. A fence secured the entire backyard. All outdoor pathways were free of obstructions. No bodies of water were observed. There were no firearms or ammunition observed at the facility, and LPA was informed the facility will not store firearms or ammunition on the premises.

During today's visit, LPA did not observe any deficiencies. An exit interview was conducted, and a copy of this report was reviewed and provided to Licensee Quinlan.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023

LIC809 (FAS) - (06/04)

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