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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336406991
Report Date: 09/01/2022
Date Signed: 09/01/2022 03:25:01 PM


Document Has Been Signed on 09/01/2022 03:25 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



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: 13DATE:
09/01/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:56 PM
MET WITH:Maria Martinez, Lead CargiverTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Chinwe Nwogene arrived unannounced to the facility to conduct a case management visit in conjunction with complaint control number 18-AS-20220829173917 to check on the health, safety, and welfare of residents in care. LPA met with Lead Caregiver, Maria Martinez and explained the purpose of the visit.

During the visit, LPA toured the inside and outside perimeter of the facility with Maria Martinez and observed no health and/or safety hazards. LPA observed 13 residents in care. LPA observed all facility utilities to be on and operating without issue. There was sufficient amount of staff present at the facility to provide care. LPA assessed the available food supply and observed that the supply exceeds the requirement of a two (2) day supply of perishable foods and a seven (7) day supply of non-perishable foods. Medications were observed to be locked and inaccessible to residents as appropriate.

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, and no deficiencies were cited during the visit. An exit interview was conducted, and a copy of this report was provided to Maria Martinez
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Chinwe NwogeneTELEPHONE: (951) 202-2066
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2022
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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