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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336406991
Report Date: 06/08/2021
Date Signed: 06/08/2021 10:46:34 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/26/2021 and conducted by Evaluator Stephanie Williams
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210526095640
FACILITY NAME:OUR COUNTRYSIDE RESORTFACILITY NUMBER:
336406991
ADMINISTRATOR:SANTIAGO/COMLEY/GARCIAFACILITY TYPE:
740
ADDRESS:18111 HAINES ST.TELEPHONE:
(951) 657-3557
CITY:PERRISSTATE: CAZIP CODE:
92570
CAPACITY:36CENSUS: 16DATE:
06/08/2021
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Valerie GarciaTIME COMPLETED:
11:00 PM
ALLEGATION(S):
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Facility denied access to Ombudsman.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Stephanie Williams conducted a visit to the facility in order to deliver findings for the above allegation. LPA met with Administrator, Valerie Garcia, and discussed the purpose of the visit. The investigation consisted of interviews with staff members.

LPA interviewed Staff #1 (S1) who stated that an Ombudsman representative arrived at the facility and requested a copy of the resident roster, to which was provided to the representative, according to S1. The Ombudsman representative also requested to come inside the facility; however, since the representative did not have appropriate Personal Protective Equipment (PPE), the representative decided to stay outside of the facility, according to S1. Due to lack of information and/or evidence to corroborate the allegation; the allegation is unsubstantiated.

Based on evidence obtained during today’s visit, the LPA has determined that the above allegation is UNSUBSTANTIATED; meaning that although the allegation may have happened or is valid, there is not a
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie WilliamsTELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 18-AS-20210526095640
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: OUR COUNTRYSIDE RESORT
FACILITY NUMBER: 336406991
VISIT DATE: 06/08/2021
NARRATIVE
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preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted where this report was discussed and a copy was provided to the Administrator.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie WilliamsTELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2