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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336406991
Report Date: 05/02/2024
Date Signed: 05/02/2024 04:36:12 PM


Document Has Been Signed on 05/02/2024 04:36 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
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: 16DATE:
05/02/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Resident Care Director, Vivian OnwunaliTIME COMPLETED:
04:15 PM
NARRATIVE
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On 5/2/2024, Licensing Program Analyst (LPA) Janette Romero conducted an unannounced visit at the facility to address a deficiency observed during investigation of a complaint. LPA met with Resident Care Director (RCD), Vivian Onwunali who was informed of the purpose of the visit.

During investigation of a complaint involving Resident 1 (R1), LPA was informed by RCD Onwunali that the facility confiscated R1's personal cell phone due to fear of potential financial abuse. Pursuant to Tittle 22 regulation, residents have the right to keep and use their own personal possessions. In addition, the potential financial abuse incident was not reported to Community Care Licensing.

As a result, the facility will be cited pursuant to Title 22 regulations 87468.1(a)(12) and 87211(a). A civil penalty will also be assessed. An exit interview was conducted and a copy of this report was reviewed and provided to RCD Onwunali along with an LIC809-D, Confidential Names List (LIC811), LIC421FC and Appeal Rights.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janette RomeroTELEPHONE: (951) 529-2930
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 05/02/2024 04:36 PM - 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: 05/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/13/2024
Section Cited
CCR
87468.1(a)(12)

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(a) Residents in all residential care facilities for the elderly... (12) To wear their own clothes; to keep and use their own personal possessions... This requirement was not met as evidenced by:
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Licensee stated the facility will conduct a personal rights training for all staff and management and provide proof of training to LPA by close of business on POC due date.
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During a complaint investigation, LPA was informed the facility confiscated Resident 1's (R1's) personal cell phone. This poses a potential personal rights risk to residents in care.
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Type B
05/13/2024
Section Cited
CCR87211(a)

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(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: This requirement was not met as evidenced by:
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Licensee stated the facility will conduct a training regarding reporting requirements and provide proof of training to LPA by close of business on POC due date.
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LPA was informed that the facility suspected potential financial abuse against R1 and a report was not submitted to Community Care Licensing. This poses a potential health, safety and/or personal rights 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: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janette RomeroTELEPHONE: (951) 529-2930
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2