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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006428
Report Date: 09/27/2024
Date Signed: 09/27/2024 11:38:06 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/18/2024 and conducted by Evaluator Dwayne L Mason
COMPLAINT CONTROL NUMBER: 22-AS-20240918141952
FACILITY NAME:COUNTRY CLUB SENIOR HOME CAREFACILITY NUMBER:
306006428
ADMINISTRATOR:ABUDA, MA TERESAFACILITY TYPE:
740
ADDRESS:8271 COUNTRY CLUB DRIVETELEPHONE:
(909) 900-6064
CITY:BUENA PARKSTATE: CAZIP CODE:
90621
CAPACITY:6CENSUS: 4DATE:
09/27/2024
UNANNOUNCEDTIME BEGAN:
09:01 AM
MET WITH:Gary Tadeo, Heidi Tadeo (Administrators); Peppi Pala (Licensee)TIME COMPLETED:
11:53 AM
ALLEGATION(S):
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Facility does not have a qualified Administrator
Facility has not notified Licensing of their new Administrator
INVESTIGATION FINDINGS:
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Dwayne Mason Jr.
for the purpose of initiating the investigation into the above-mentioned complaint allegations. LPA
met with Administrator (AD1) Gary Tadeo and discussed the purpose of the inspection. Administrator (AD2) Heidie Tadeo and Licensee (L) Peppi Pala joined the inspection as well.

LPA conducted interviews with Administrators and Licensee. LPA obtained copies of the Personnel Report, Resident roster, Administrator Certification for AD1 and AD2, receipt for registered mail sent to the Department on 6/18/2024 and proof of delivery indicating the notification was delivered on 6/19/2024. LPA observed the address the notification was sent to was incorrect. LPA provided the facility with the correct address and advised them to continue reaching out the Department if they do not receive any communication in return.

(continued on LIC9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024
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 2
Control Number 22-AS-20240918141952
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: COUNTRY CLUB SENIOR HOME CARE
FACILITY NUMBER: 306006428
VISIT DATE: 09/27/2024
NARRATIVE
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(continued from LIC9099)

Based on interviews conducted and records reviewed, LPA determined the facility replaced their Administrator with a qualified candidate within 30 days as required by Title 22 Regulations. LPA determined that, although the facility sent the notification to the incorrect address, they otherwise took appropriate action to notify the Department within the 30 days as required by Title 22 Regulations.

Based on interviews conducted and records reviewed, LPA determined that due the facility's actions following the resignation of their previous Administrator and due to the facility having no similar previous citations, there is insufficient evidence to support the allegation. Although the allegation may have happened or is valid; there is not a preponderance of evidence to prove that the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

An exit interview was conducted, and this report was reviewed with facility staff. A copy of this LIC-9099 was provided to the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2