336406991-2-7-2023-18-AS-DMUN-CNX32P-20230210165216

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336406991
Report Date: 02/07/2023
Date Signed: 02/07/2023 02:49:49 PM

Unsubstantiated

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
08/29/2022 and conducted by Evaluator Chinwe Nwogene

COMPLAINT CONTROL NUMBER: 18-AS-20220829173917

FACILITY NAME:	OUR COUNTRYSIDE RESORT		FACILITY NUMBER:	336406991
ADMINISTRATOR:	SANTIAGO/COMLEY/GARCIA		FACILITY TYPE:	740
ADDRESS:	18111 HAINES ST.		TELEPHONE:	(951) 657-3557
CITY:	PERRIS	STATE: CA	ZIP CODE:	92570
CAPACITY:	36	CENSUS: 19	DATE:	02/07/2023
		UNANNOUNCED	TIME BEGAN:	02:14 PM
MET WITH:	Valerie Garcia, Administrator		TIME COMPLETED:	02:55 PM

ALLEGATION(S):

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Facility is neglecting resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Chinwe Nwogene conducted an unannounced visit to conclude the complaint investigation into the allegation listed above. LPA met with Administrator, Valerie Garcia and explained the purpose of the visit. During the investigation, LPA interviewed staff, interviewed residents, interviewed Resident #1’s Responsible Party and reviewed resident’s file.
Regarding the allegation “facility is neglecting resident”. It was alleged staff is neglecting Resident #1 (R1). LPA interviewed staff who denied neglecting resident. Staff stated care and supervision is provided to all residents. LPA interviewed residents. Three out of three residents interviewed denied staff neglect residents. LPA interviewed Resident #1’s Responsible Party who denied hearing about staff neglecting resident #1. Resident’s RP reported resident is properly cared for by staff. Resident’s file review revealed no evidence of staff neglecting resident.
Based on LPA’s interviews and resident’s file review, there is not enough evidence to support the above allegation. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations is unsubstantiated at this time. An exit interview was conducted, and a copy of this report was reviewed with and provided to Valerie Garcia.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Chinwe Nwogene	TELEPHONE: (951) 202-2066
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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