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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336406991
Report Date: 04/09/2024
Date Signed: 04/09/2024 04:16:37 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 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
04/05/2024 and conducted by Evaluator Crystal Colvin
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20240405093858
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: 22DATE:
04/09/2024
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Nurse Vivian Onwunali-MaxwellTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Licensee did not request a transfer of staffs criminal record clearance

Facility ceiling is in disrepair

Facility staff are not dispensing medication as prescribed
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced in order to conduct an investigation of a complaint with the above allegation(s). LPA identified herself and discussed the purpose of the visit and the elements of the allegation(s) with President Michelle MaGee. Below is a summary of the complaint investigation findings:

Regarding allegation "Licensee did not request a transfer of staffs criminal record clearance": LPA Colvin conducted a review of the facility's roster in Guardian, which reflects all staff who have had their criminal record clearance transferred to the facility. LPA Colvin compared this with the facility's staff schedule and observed six staff members (S1 - S6) who have been present at the facility working without having thier criminal record clearance transferred. President Michelle McGee additionally confirmed with LPA Colvin that this has not been completed yet and would be done today. Therefore, based on record review and interview, the allegation "Licensee did not request a transfer of staffs criminal record clearance" is SUBSTANTIATED.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2024
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 7
Control Number 18-AS-20240405093858
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 04/09/2024
NARRATIVE
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Violations of criminal record clearance, including not having staff's clearance transferred to the facility prior to them working in the facility, results in a civil penalty of $100 a day, per staff, per day worked, for a maximum of $500 per staff (unless the regulation is violated again within a 12 month period). Therefore, LPA Colvin will be assessing civil penalties as follow:
  • Staff 1 (S1) - $200 for the dates of 4/8/24 & 4/9/24
  • Staff 2 (S2) - $100 for the date of 4/8/24
  • Staff 3 (S3) - $400 for the dates of 4/1/24, 4/2/14, 4/5/24, & 4/6/24
  • Staff 4 (S4) - $500 for the dates of 4/1/24, 4/2/14, 4/5/24, 4/6/24, 4/7/24, & 4/8/24 (maxed out at 5)
  • Staff 5 (S5) - $300 for the dates of 4/4/14, 4/5/24, & 4/6/24
  • Staff 6 (S6) - $500 for the dates of 3/8/24 - 4/9/24 (maxed out at 5)


Total amount of civil penalties being assessed is $2,000.

Regarding allegation "Facility ceiling is in disrepair": LPA Colvin toured the facility, including resident bedrooms, and observed that resident rooms #10, #15, & #17 all had holes in the bathroom ceilings where recent plumbing work had been done. Facility staff informed LPA Colvin that no resident was currently living in room #17, but rooms #10 & #15 were both occupied. Therefore, based on observation, the allegation "Facility ceiling is in disrepair" is SUBSTANTIATED.

Regarding allegation “Facility staff are not dispensing medication as prescribed”: LPA Colvin conducted interviews with staff and residents, as well as reviewed facility medication records and physical medication for a random sampling of residents. LPA Colvin observed one medication (M1) for Resident One (R1) was not administered for the PM dose on 4/8/24, but the facility’s Medication Administration Record (MAR) is signed off for that administration. Additionally, LPA Colvin observed that two medications (M2 & M3) for Resident Two (R2) have multiple doses that were not administered in the month of April 2024. Nurse Vivian Onwunali-Maxwell stated that R2 is on Hospice and they are discontinuing all of R2’s medications (except for as-needed medications), though the facility does not have the discontinuation order yet. LPA Colvin observed that while R2 has doses of medication for April administered, which are intermixed with the dates not administered (therefore, there was no ceasing of medication administration). LPA Colvin also observed R2's PM doses for M2 & M3 have not been administered in April. Therefore, due to the medication discrepancies observed, the allegation “Facility staff are not dispensing medication as prescribed” is SUBSTANTIATED.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 18-AS-20240405093858
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/10/2024
Section Cited
CCR
87355(e)(2)
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Criminal Record Clearance: (e) All individuals ...shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)... This requirement was not met by:
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President agrees to request background clearance transfers for all staff by Plan of Correction date of 4/10/24. President may self-ceritfy to LPA Colvin by Plan of Correction date of 4/10/24, and LPA Colvin will verify once complete.
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Based on record review, the Licensee did not comply with the above regulation with 7 staff. LPA Colvin observed that S1 - S7 were physically working in the facility without having had their criminal record clearance transferred to the facility. This is an immediate safety risk to residents in care.
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Type B
04/23/2024
Section Cited
CCR
87303(a)
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Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times.... This requirement was not met as evidenced by:
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President states that they will have a protective barrier placed to cover the holes until they are fully corrected. President agrees to submit photographic proof of fixed bathrooms by Plan of Correction date of 4/23/24.
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Based on observations, the Licensee did not comply with the above regulation with three resident bedrooms. LPA Colvin observed holes in the bathroom ceilings in resident rooms #10, #15, & #17. This is a potential 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: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 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
04/05/2024 and conducted by Evaluator Crystal Colvin
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20240405093858

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: 22DATE:
04/09/2024
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Nurse Vivian Onwunali-MaxwellTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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9
Facility staff are not providing clients with assistance in cleaning their rooms
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced in order to conduct an investigation of a complaint with the above allegation(s). LPA identified herself and discussed the purpose of the visit and the elements of the allegation(s) with President Michelle MaGee. Below is a summary of the complaint investigation findings:

Regarding allegation "Facility staff are not providing clients with assistance in cleaning their rooms": LPA Colvin conducted staff interviews and toured the facility, inspecting 6 resident bedrooms. LPA Colvin observed all 6 bedrooms to be tidy and clean. Staff interviews reveal that caregivers clean the resident bedrooms daily. President Michelle McGee additionally stated that they have a seperate housekeeping schedule to ensure cleanliness. Based on the lack of evidence to support the claim, the allegation "Facility staff are not providing clients with assistance in cleaning their rooms" is UNSUBSTANTIATED.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 18-AS-20240405093858
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 04/09/2024
NARRATIVE
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A finding of UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted with Nurse Vivian Onwunali-Maxwell during the exit interview, as President Michelle MaGee had to leave, and a copy of this report was provided.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 18-AS-20240405093858
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 04/09/2024
NARRATIVE
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A finding that the complaint is SUBSTANTIATED means that the allegation(s) is valid because the preponderance of the evidence standard has been met.

Due to observations made by LPA Colvin, the facility was cited, and deficiencies noted on LIC 9099 D. An exit interview was conducted where this report and appeal rights were discussed. A copy this report, LIC 9099D, LIC421BG, and appeal rights were provided to Nurse Vivian Onwunali-Maxwell during the exit interview, as President Michelle MaGee had to leave.

SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 18-AS-20240405093858
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/23/2024
Section Cited
CCR
87465(a)(4)
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Incidental Medical and Dental Care: (a) ... shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed.
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Facility Nurse is going to obtain a discontinuation order for R2 as well as conduct training for incoming Medication Technicians. Facility Nurse to provide discontinuation order to LPA Colvin by Plan of Correction date of 4/23/24 along with staff
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This requirement was not met by: Based on observations and record review, the Licensee did not comply with the above regulation with two residents (R1 & R2). Medications for R1 & R2 were not administered as prescribed in April 2024. This is a potential health risk to R1 & R2.
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training records.
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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: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 7