<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 372004630
Report Date: 09/13/2023
Date Signed: 09/13/2023 09:59:18 AM

Substantiated


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
02/15/2023 and conducted by Evaluator Tricia Danielson
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20230215123217
FACILITY NAME:COUNTRY CLUB GUEST HOMEFACILITY NUMBER:
372004630
ADMINISTRATOR:RAMIREZ, JULIEFACILITY TYPE:
740
ADDRESS:25533 RUA MICHELLETELEPHONE:
(760) 747-0957
CITY:ESCONDIDOSTATE: CAZIP CODE:
92026
CAPACITY:30CENSUS: 23DATE:
09/13/2023
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Kevin Ramirez, Co-AdministratorTIME COMPLETED:
10:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff yell at residents
Staff are not providing adequate food service to residents
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to conclude an investigation into the allegations listed above. LPA met with Co-Administrator Kevin Ramirez and explained the purpose of the visit. Regarding the allegation "Staff yell at residents", it was alleged that Staff #1(S1) yells at the residents. Five (5) of nine (9) residents interviewed reported either having been yelled at by S1 or observing S1 yelling at a resident. Five (5) staff of five (5) staff interviewed denied ever yelling at a resident, observing a staff yell at a resident, or hearing of a staff yelling at a resident. Regarding the allegation "Staff are not providing adequate food service to residents", it was alleged that foods are served cold when they should be hot. Five (5) of nine (9) residents interviewed reported foods such as burritos, pizza, oatmeal, pasta, sausages, quesadillas, soup, grilled cheese sandwiches, and chili are often served cold. Five (5) of five (5) staff interviewed denied food is served cold or every hearing of complaints about food being served cold. Based on interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. (CONTINUED ON LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) -24-0313
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 18-AS-20230215123217
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: COUNTRY CLUB GUEST HOME
FACILITY NUMBER: 372004630
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/14/2023
Section Cited
CCR
87465(a)(1)
1
2
3
4
5
6
7
Personal Rights of Residents in All Facilities- (a)Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requiremet was not met as evidenced by:
1
2
3
4
5
6
7
Licensee will retrain all staff on the importance of maintaining the personal rights of all residents. Proof of training to be submitted to CCL by 5 PM 9/14/2023.
8
9
10
11
12
13
14
The licensee did not ensure residents' dignity was maintained. Based on interviews conducted, 5 of 9 residents reported S1 yells at residents. This poses an immediate health, safety, and personal rights risk to residents in care.
8
9
10
11
12
13
14
Type B
09/22/2023
Section Cited
CCR
87555(b)(9)
1
2
3
4
5
6
7
General Food Service Requirements-(b) The following food service requirements shall apply: (9)Procedures which protect the safety, acceptability...of food shall be observed in food...service. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee will retrain food prep staff to ensure food is served at apporopriate temperatures. Proof of training to be submitted to CCL by 5PM 9/22/2023
8
9
10
11
12
13
14
The licensee did not ensure food service requirements were met. Based on interviews conducted, 5 of 9 residents reported food is often served cold. This poses a potential health, safety, and personal rights risk to residents in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) -24-0313
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4
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
02/15/2023 and conducted by Evaluator Tricia Danielson
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20230215123217

FACILITY NAME:COUNTRY CLUB GUEST HOMEFACILITY NUMBER:
372004630
ADMINISTRATOR:RAMIREZ, JULIEFACILITY TYPE:
740
ADDRESS:25533 RUA MICHELLETELEPHONE:
(760) 747-0957
CITY:ESCONDIDOSTATE: CAZIP CODE:
92026
CAPACITY:30CENSUS: DATE:
09/13/2023
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Julie Ramirez, Licensee/AdministratorTIME COMPLETED:
10:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff handle residents in a rough manner
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to conclude an investigation into the allegations listed above. LPA met with Licensee/Administrator Julie Ramirez and explained the purpose of the visit.
Regarding the allegation "Staff handle residents in a rough manner", it was alleged Staff #1 (S1) pushed a resident down into their seat. Two (2) of nine (9) residents interviewed reported either having been pushed by S1 or observing S1 push a resident down into their seat. Five (5) of five (5) staff interviewed denied pushing a resident, observing a staff push a resident, or ever hearing of a staff push as resident.
Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted and a copy of this report was provided along with LIC811- Confidential Names list.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) -24-0313
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 18-AS-20230215123217
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: COUNTRY CLUB GUEST HOME
FACILITY NUMBER: 372004630
VISIT DATE: 09/13/2023
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
26
27
28
29
30
31
32
(CONTINUED FROM LIC 9099)
California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099 D. An exit interview was conducted and a copy of this report was provided along with LIC811- Confidential Names list and Appeal Rights.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) -24-0313
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4