372004630-8-29-2023-18-AS-CGOH-CV6VUW-20230829164525

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 372004630
Report Date: 08/29/2023
Date Signed: 08/29/2023 04:45:31 PM

Document Has Been Signed on 08/29/2023 04:45 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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	COUNTRY CLUB GUEST HOME		FACILITY NUMBER:	372004630
ADMINISTRATOR:	RAMIREZ, JULIE		FACILITY TYPE:	740
ADDRESS:	25533 RUA MICHELLE		TELEPHONE:	(760) 747-0957
CITY:	ESCONDIDO	STATE: CA	ZIP CODE:	92026
CAPACITY:	30	CENSUS: 23	DATE:	08/29/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Administrator, Julita Ramirez		TIME COMPLETED:	04:46 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 08/29/23 at 2:30 p.m. Licensing Program Analyst (LPA) Cheryl Goodrich arrived to conduct an unannounced annual visit. LPA met with Caregiver Clara Aguas at the front door and was granted entry. The Administrator, Julita Ramirez arrived at 3:06 p.m. The purpose of today’s visit is to inspect the facility to ensure that the facility is following California Code of Regulations, Title 22, Division 6. Facility is approved for thirty (30) ambulatory residents, having 23 residents in care. Infection Control: The facility has an approved infection control plan and a surplus of supplies for infection control including but not limited to mask, gloves, gowns, first aid kit, and cleaning supplies. Physical Plant and Environmental Safety: There are a total of 24 resident bedrooms, and 10 bathrooms, a kitchen, living room, office area, backyard area with furniture for residents and staff. All rooms, living room, office area, kitchen and dinning room are all clean and clear of obstruction. The resident bedrooms were clean and clear from obstruction. The resident’s rooms were complete with and clean linens and bedding, dresser, and closet space. The bathroom water temperature read at 108.2 degree. Operational Requirements: The facility was staffed with 3 caregivers. The facility meets the operational requirements for an RCE and has a current fire clearance for the facility, smoke and carbon monoxide detectors and fire extinguisher. (Continued on LIC809-C)

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Cheryl Goodrich	TELEPHONE: 951-248-0308
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: COUNTRY CLUB GUEST HOME	FACILITY NUMBER: 372004630
	VISIT DATE: 08/29/2023

NARRATIVE

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(Continued from LIC809)

Personnel Records-Training: All staff have fingerprint clearances, current CPR/First Aid certification, Health screen and TB test completed. All staff complete monthly in-service training and fire-drills and disaster training.
Client Records-Incident Reports: The resident records are complete with pre-assessments, admissions agreement, physician reports, identification and emergency information, , house rules, medication log, daily logs of the resident’s health condition, and additional medical assessments.
Client Rights-Information: The resident’s right documentation is present. The resident records also contain needs assessment information for each resident.
Food Service: 7-day non-perishable and 2 day of perishable food supply was observed, and all food was properly stored and available to residents.
Health- Related Services: The caregivers at the facility are dispensing medications within the guidelines of the physician’s order and the regulations. The facility is documenting the date and time of the dispensing of medication for each resident.
Disaster Preparedness: The facility has a disaster plan and has posted the evacuation plan, visible for staff and residents in care. The last fire drill was completed 08/02/23. The facility has emergency supply of food and water.
Summary: Based on today's visit, no deficiencies were observed at this time. An exit interview was conducted with Administrator, Julita Ramirez and a copy of this report was printed Signature below confirms receipt of these rights.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Cheryl Goodrich	TELEPHONE: 951-248-0308
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023

LIC809 (FAS) - (06/04)

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