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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 372004630
Report Date: 08/08/2024
Date Signed: 08/09/2024 04:23:39 PM


Document Has Been Signed on 08/09/2024 04:23 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



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: 28DATE:
08/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Julie Ramirez, Licensee/Administrator TIME COMPLETED:
11:00 AM
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On 08/08/24 at 8:45am Licensing Program Analyst (LPA) Javina George made an unannounced visit for the purpose of conducting a 1 year required visit/annual inspection. LPA George met with Licensee/Administrator Julie Razmirez and informed her of the purpose of today's visit. The facility is licensed to serve (30) Elderly clients age 60 years and above (18) non ambulatory and (12) ambulatory. The facility has an approved hospice waiver for (1), with (0) resident's receiving hospice services. Below is a summary of what was observed during today’s inspection:

Infection Control: LPA George observed that the facility has an updated Infection Control Plan on file and is demonstrating best practices in the facility to maintain a healthy environment for staff and residents. The facility was observed to have an adequate supply of Personal Protective Equipment (PPE) supplies.

Physical Plant: LPA toured the interior and exterior of the facility and observed that there a sufficient bedrooms (24) and bathrooms (12) for client use. The facility was observed to have the required furniture and linen to be present and in good condition in resident bedrooms. The exits are not obstructed and that there is plenty of space for activities. There is an activities calendar posted on the white board. There are no pools or bodies of water on the premises.

Staff Records: LPA observed that there are sufficient staff present to meet the needs of clients. LPA George additionally confirmed that there is an Administrator present with a valid certificate that expires April 2025. LPA observed for staff present to have criminal record clearance and were associated to the facility and have training to perform their required duties. Staff present at have current CPR/First Aid Certification. In addition LPA verified facility contact information was up to date.

Resident Records: A review of (3) client files including Physician's Report, Admissions Agreement, and current Needs & Services Plan. The client's are assisted with cashing their checks, and are responsible for there money thereafter therefore no Personal and Incidental funds were reviewed during today's inspection.

SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 08/08/2024
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Food Services: The kitchen and dining area to be maintained in a clean and healthful manner. The facility was observed to have sufficient dishware and silverware were present for resident’s use. There were graham crackers, cereal, fruit cups and 2 bottles of salad dressing, that were observed to have expired. The items were discarded at the time of LPAs visit, therefore no citations were issued. LPA observed the facility to have the required amount of 7 day supply non-perishable and a two supply perishable food items.

Medication: Resident medication was observed to be locked in the medication storage and inaccessible to residents. A review of medication revealed that the medication is being given as prescribed as evidenced by the Medication Authorization Record (MAR) and medication (bubble packs).

Emergency Disaster Preparedness: The facility has an Emergency Disaster Plan on file and conducts regular disaster drills on a quarterly basis. The last drill was conducted on 06/12/24, the next drill is due this month. The smoke and carbon monoxide detectors were tested and were found to be operable. The facility has (4) fully charged fire extinguishers. There are no known guns or ammunition on the premises. The hot water was tested and was found to be within regulatory limit measuring at 108-111 degrees Fahrenheit. The facility has emergency food and water supply. The sharps and hazardous chemicals were observed to be locked and inaccessible to clients in care.

Based on today's inspection no deficiencies/citations were issued. An exit interview was conducted and a copy of this report, were provided to Licensee/Administrator Julie Ramirez.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024
LIC809 (FAS) - (06/04)
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