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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336406991
Report Date: 02/07/2024
Date Signed: 02/07/2024 10:21:10 AM


Document Has Been Signed on 02/07/2024 10:21 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 ASC, 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: 20DATE:
02/07/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator, Valerie GarciaTIME COMPLETED:
10:30 AM
NARRATIVE
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On 2/7/2024, Licensing Program Analyst (LPA) Janette Romero conducted an unannounced visit to the facility and met with Administrator, Valerie Garcia.

Administrator Garcia informed LPA the facility faxed an Unusual Incident/Injury Report (LIC624) regarding Resident 1 (R1) to Community Care Licensing (CCL). However, there is no record that CCL received the LIC624 and the facility does not have a fax confirmation page to prove the LIC624 was successfully delivered to CCL. Administrator Garcia stated the facility will contact their phone company to test the fax machine's phone line and/or troubleshoot it, if necessary. LPA provided Administrator, Garcia with the Riverside Regional Office's email to submit LIC624s. LPA also advised Administrator Garcia to print fax confirmation pages if the facility submits documents to CCL via fax.

The facility will be cited pursuant to regulation 87211(a).

An exit interview was conducted where a copy of this report was reviewed and provided to Administrator Garcia along with an LIC809-D and Appeal Rights.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Janette RomeroTELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2024
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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Document Has Been Signed on 02/07/2024 10:21 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: OUR COUNTRYSIDE RESORT
FACILITY NUMBER: 336406991

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/19/2024
Section Cited
CCR
87211(a)

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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including...This requirement was not met as evidenced by:
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Licensee stated they will contact their phone company to fix any issue with the fax machine/phone line, and submit a receipt as proof of correction to LPA by COB on POC due date. Licensee stated they will email LIC624s to Riverside RO.
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Administrator Garcia informed LPA the facility submitted an Unusual Incident/Injury Report (LIC624) regarding Resident 1 (R1) to CCL via fax. However, there is no record CCL received the fax. This poses a potential health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Janette RomeroTELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2