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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336406991
Report Date: 05/29/2024
Date Signed: 05/29/2024 12:41:58 PM


Document Has Been Signed on 05/29/2024 12:41 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: 15DATE:
05/29/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
11:46 AM
MET WITH:Michelle Magee, PresidentTIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Yolanda Delgado conducted a Health and Safety checks for residents in care and during the tour of the facility with Administrator, LPA observed sufficient food, working utilities and sufficient staff for care and supervision of residents. LPA observed resident rooms with either keylocks on the exterior of the resident room doors or hole locks on exterior of the resident room doors. LPA Delgado observed a resident room door locked and staff had to be summoned to use the metal probe to unlock the door, LPA observed Resident #1 (R1) that is non-ambulatory laying in a hospital bed.

Based on observations during the visit, the facility will be cited for one (1) deficiency per Title 22, Division 6, Chapter 8.

An exit interview was conducted with Michelle Magee, LIC809, LIC809D, LIC811, Appeal Rights were reviewed with and provided to Mrs. McGhee.

SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda DelgadoTELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:
DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2024
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 05/29/2024 12:41 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
CCLD Regional Office, 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: 05/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/31/2024
Section Cited
CCR
87468.1(a)(6)

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(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (6) ...and to not be locked into any room, building, or on facility premises by day or night...
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Facility will be changing on resident room door handles with bedroom door handles and submit a self-certifying statement by email to LPA by POC due date.
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This requirement is not being met as evidenced by: LPA Delgado observed resident room door locked and R1 laying in hospital bed that is non-ambulatory. This poses a potential health and safety risk to the clients 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: Yolanda DelgadoTELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:
DATE: 05/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2024
LIC809 (FAS) - (06/04)
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