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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 371881380
Report Date: 01/03/2024
Date Signed: 01/03/2024 03:04:34 PM


Document Has Been Signed on 01/03/2024 03:04 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:COUNTRY GARDENSFACILITY NUMBER:
371881380
ADMINISTRATOR:CASTELLANOS, JENNYFACILITY TYPE:
740
ADDRESS:1504 HILLCREST LANETELEPHONE:
(951) 218-8130
CITY:FALLBROOKSTATE: CAZIP CODE:
92028
CAPACITY:16CENSUS: 14DATE:
01/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:28 PM
MET WITH:LEAD CAREGIVER, DELOS SANTOS ROSETIME COMPLETED:
03:18 PM
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On January 03, 2023, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced to conduct the required annual inspection and spoke with the Administrator, Jenny Castellanos via the telephone, and interviewed her. The facility file review was conducted in the office.

LPA Mixson toured the facility along with the Lead Caregiver, Rose, and inspected the facility inside and outside, and there were no obstructions to the indoor or outdoor passageways at the time of this visit. The facility is a two-story home, located at 1504 Hillcrest Lane Fallbrook, CA 92028. Physical Plant: The facility phone number is (951) 216-8130 and is operable. The LPA observed the residents bedrooms, and they are equipped with required furniture as per Title 22. The LPA inspected facility bathrooms, and the hot water temperature was tested and tested within regulations. The bathrooms were clean and appliances were operating appropriately currently at the time of this visit. The facility is equipped with operating smoke detectors, carbon monoxide alarms, and fire extinguishers. The LPA observed required postings such as "If you See Something, Say Something" the "Personal Rights" and the Ombudsman postings were posted in a common area. The cleaning supplies and sharp items were kept locked and inaccessible to the residents in care. There was a designated storage space for the resident and staff files and they were locked and inaccessible to residents in care. Medications: were reviewed, locked and inaccessible to residents, and there was a 30 day supply. The overall facility is clean, the furniture is in good condition. The facility heating system and other appliances were operable currently at the time of this visit. Food Service: Non-perishable and perishable food supply is sufficient per regulations, and there are a variety of food types available for residents. Dishes and utensils were in sufficient supply and stored properly. Care & Supervision Facility has sufficient staff, three staff at the time of this visit and the staff were engaging the residents in activities. Records Review: The LPA reviewed six resident files, and four staff files, and conducted two staff interviews, and four resident interviews. Previous Community Care Licensing forms were reviewed. There were no Title 22, Division 6 Regulation violations observed or cited during today’s visit. An exit interview was conducted and a copy of this report was given to the Lead Caregiver, Rose.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus MixsonTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:
DATE: 01/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/03/2024
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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