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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 371881380
Report Date: 01/12/2023
Date Signed: 01/12/2023 10:52:35 AM

Document Has Been Signed on 01/12/2023 10:52 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:COUNTRY GARDENSFACILITY NUMBER:
371881380
ADMINISTRATOR:CASTELLANOS, JENNYFACILITY TYPE:
740
ADDRESS:1504 HILLCREST LANETELEPHONE:
(951) 218-8130
CITY:FALLBROOKSTATE: CAZIP CODE:
92028
CAPACITY: 16CENSUS: 15DATE:
01/12/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:ADMINISTRATOR, JENNY CASTELLANOS.TIME COMPLETED:
11:00 AM
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On January 12, 2023, Licensing Program Analyst (LPA), Venus Mixson conducted a scheduled visit to complete a Pre-licensing inspection. LPA Mixson met with Administrator, Jenny and toured the facility inside and outside. The facility is a single story home with eight bedrooms, four baths, kitchen, dinning room, and living room. LPA Mixson observed sufficient food supply, and the overall facility to be in clean condition with a comfortable temperature. LPA Mixson observed passageways to be free from obstruction. Water temperature was tested and found to be within regulations. LPA Mixson observed medications were locked and inaccessible to clients. LPA observed smoke alarms/ carbon monoxide detectors are hardwire and operable. The Fall brook Fire Department cleared home on 11/05/2022, for 0 ambulatory, 8 non ambulatory, and 8 bedridden residents. LPA Mixson observed food storage and preparation areas. Food preparation areas are clean and sanitary. Refrigerator and freezer are maintained at appropriate temperatures. The kitchen was observed to have dishes, silverware and pots and pans. All appliances are clean and operating properly. There is a sufficient supply of linens, towels and personal hygiene items. The first aid kit was reviewed; all items are present. LPA Mixson observed a dining area with sufficient seating for 16 residents. Outdoor space is suitable for residents use and was observed to be fully fenced with a locked gate. The fire extinguishers are completely charged and maintained, LPA observed five extinguishers.
The Administrator dialed 760-645-3102 and number was in working order.
An exit interview was conducted and a copy of this report was reviewed and given to the Administrator. COMP III reviewed.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE: DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/12/2023
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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