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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 371881380
Report Date: 01/17/2025
Date Signed: 01/17/2025 10:58:41 AM

Document Has Been Signed on 01/17/2025 10:58 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:COUNTRY GARDENSFACILITY NUMBER:
371881380
ADMINISTRATOR/
DIRECTOR:
CASTELLANOS, JENNYFACILITY TYPE:
740
ADDRESS:1504 HILLCREST LANETELEPHONE:
(951) 218-8130
CITY:FALLBROOKSTATE: CAZIP CODE:
92028
CAPACITY: 16CENSUS: 12DATE:
01/17/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Administrator, Jenny CastellanosTIME VISIT/
INSPECTION COMPLETED:
11:10 AM
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On 1/17/2025, Licensing Program Analyst (LPA) Janette Romero arrived unannounced to conduct a required annual inspection. LPA was greeted and granted entry by Caregiver, Ron Lao who was informed of the purpose of the visit. Administrator, Jenny Castellanos arrived during the visit and was also informed of the purpose of the visit. The facility has a fire clearance to serve sixteen (16) non-ambulatory elderly residents, of which eight (8) may be bedridden. The facility also has an approved hospice waiver for six (6) and is approved for a secured perimeter.

LPA toured the facility's interior and exterior with Caregiver, Rosemarie Dela Cruz. LPA observed eight (8) resident bedrooms, four (4) resident restrooms, two (2) living rooms, a kitchen, dining room, and staff office. Resident bedrooms had the required bedding, furniture, and lighting. Bathrooms had grab bars and non-skid mats in the showers. LPA did not observe any bodies of water on the premises. Indoor and outdoor passageways were free of obstruction. The facility met Departmental requirements for a two-day supply of perishable foods and seven-day supply of non-perishable foods, which were stored in a safe and healthful manner. Medications are stored in a locked medication cart secured in the locked medication room. LPA observed additional incontinent supplies, linens, blankets, towels, and hygiene supplies available for the residents in care. Cleaning solutions and knives are secured in different locked storage closets. Facility staff tested one (1) of the smoke alarms/carbon monoxide detectors and LPA observed it to be operational. LPA also observed charged fire extinguishers mounted throughout the facility, which were last serviced on 6/29/2024. The facility's certificate of liability insurance expires on 7/1/2025. Staff present have a criminal record clearance and are associated with the facility. LPA reviewed random staff and resident files. Staff files reviewed had a criminal record clearance and valid first aid/CPR certification. Resident files reviewed had updated physician's reports and signed admission agreements. Long Term Care Ombudsman information, complaint procedures, facility sketch, and emergency phone numbers are visibly posted near the dining room. During today's visit, LPA did not observe any issues or concerns. An exit interview was conducted and a copy of this report was reviewed and provided to Administrator Castellanos.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2025
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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