336406991-5-27-2025-18-AS-RSTS-DH6M49-20250530091620

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336406991
Report Date: 05/27/2025
Date Signed: 05/27/2025 02:50:26 PM

Unfounded

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
07/22/2024 and conducted by Evaluator Seo Jeon

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20240722083508

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:	0	CENSUS: 0	DATE:	05/27/2025
		UNANNOUNCED	TIME BEGAN:	10:12 AM
MET WITH:	Michelle Magee, ex-licensee		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Staff left resident outside for an extended period.
Staff does not ensure call button is accessible to residents.
Staff does not ensure resident is provided clean linen.
Staff does not ensure feces is properly disposed.
Staff does not ensure resident's room is clean.
Facility is key locked entry doors.
Resident's bedrooms are keyed lock entry doors.
Resident's rooms are malodorous.
Staff does not ensure facility is free of pests.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Seo Jeon mailed this report to the ex-licensee's last known mailing address via USPS certified mail, to communicate the findings related to the above-mentioned allegations. The facility has been closed since 03-01-2024.

On 07-22-2024, Community Care Licensing (CCLD) received a complaint report with above noted allegations. LPA conducted resident and staff interviews, conducted records review, and obtained supporting documentation to aid in determining the findings of the noted allegations.

Records review revealed the previous operator, operated an unlicensed operation from 03-01-2024 through 10-16-2024 at the above location.

Continued on LIC9099-C....

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Seo Jeon	TELEPHONE: 951-248-0309
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2025

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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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
07/22/2024 and conducted by Evaluator Seo Jeon

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20240722083508

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:	0	CENSUS: 0	DATE:	05/27/2025
		UNANNOUNCED	TIME BEGAN:	10:12 AM
MET WITH:	Michelle Magee, ex-licensee		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Staff does not ensure residents are provided a food menu.

INVESTIGATION FINDINGS:

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Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Seo Jeon	TELEPHONE: 951-248-0309
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2025

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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Control Number 18-AS-20240722083508

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: 05/27/2025

NARRATIVE

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Information obtained from records reviewed revealed all of the above-mentioned allegations occurred reportedly during the time period the facility was operating unlicensed. The operator was operating unlicensed from 03-01-2024 to 10-16-2024 time period.

Based on record reviews, staff and resident interviews, this allegation is Unfounded. A finding of Unfounded means the allegation could not have happened, is false, and/or is without a reasonable basis.

An exit interview was not conducted as the facility has been closed since 03-01-2024. A copy of this report was sent to the ex-licensee’s last known address via USPS certified mail, due to the facility closure.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Seo Jeon	TELEPHONE: 951-248-0309
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2025

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20240722083508

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: 05/27/2025

NARRATIVE

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SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Seo Jeon	TELEPHONE: 951-248-0309
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2025

LIC9099 (FAS) - (06/04)

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