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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300600977
Report Date: 03/17/2025
Date Signed: 03/17/2025 02:41:01 PM

Document Has Been Signed on 03/17/2025 02:41 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:TOWN & COUNTRYFACILITY NUMBER:
300600977
ADMINISTRATOR/
DIRECTOR:		SARA MODUGNOFACILITY TYPE:
741
ADDRESS:555 E. MEMORY LANETELEPHONE:
(714) 547-7581
CITY:SANTA ANASTATE: CAZIP CODE:
92706
CAPACITY: 328CENSUS: 104DATE:
03/17/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:40 PM
MET WITH:Sara ModugnoTIME VISIT/
INSPECTION COMPLETED:
03:00 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
Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to follow up on an incident report received by the department on 01/28/2025. LPA was greeted and granted entry into the facility and explained the reason for the visit.

Incident report dated 01/25/2025 indicated Resident 1 (R1) had been served shrimp for lunch while having a seafood allergy. LPA observed facility protocol for resident allergies which consists of documentation in the kitchen as well as name cards in the dining room with resident allergies/ food preferences. Facility investigation revealed a new server had mistakenly served the shrimp to R1. Another caregiver realized what had happened and removed the shrimp but not before the resident had taken a bite. Side effects for resident consumption of shrimp include diarrhea. Resident was noted to have no side effects from the shrimp. Resident has since moved out of the facility.





The following deficiency is being cited per Title 22 Division 6 of the California Code of Regulations.
An exit interview was conducted with Sara Modugno, Administrator and a copy of this report was given to the facility along with a copy of the LIC 809-D and Appeal Rights.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 03/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/17/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 03/17/2025 02:41 PM - It Cannot Be Edited


Created By: Kimberly Lyman On 03/17/2025 at 02:25 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: TOWN & COUNTRY
FACILITY NUMBER: 300600977

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/31/2025
Section Cited
CCR
87464(f)(1)

1
2
3
4
5
6
7
Basic services shall at a minimum include:
Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code
section 1569.2(c). This req is not met as evidenced by:
1
2
3
4
5
6
7
Licensee to conduct an in-service on food allergies and dining and forward proof to LPA by POC due date.
8
9
10
11
12
13
14
Based on interviews conducted and record review, Licensee failed to ensure care was provided to resident. Resident was served shrimp while resident's allergy was noted by facility. This poses a potential health and safety risk to residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Alisa Ortiz
LICENSING EVALUATOR NAME:Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:
DATE: 03/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2025


LIC809 (FAS) - (06/04)
Page: 2 of 2