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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006428
Report Date: 10/09/2024
Date Signed: 10/09/2024 12:00:33 PM

Document Has Been Signed on 10/09/2024 12:00 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
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:COUNTRY CLUB SENIOR HOME CAREFACILITY NUMBER:
306006428
ADMINISTRATOR/
DIRECTOR:		ABUDA, MA TERESAFACILITY TYPE:
740
ADDRESS:8271 COUNTRY CLUB DRIVETELEPHONE:
(909) 900-6064
CITY:BUENA PARKSTATE: CAZIP CODE:
90621
CAPACITY: 6CENSUS: 0DATE:
10/09/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:48 AM
MET WITH:Gary Tadeo, Peppi Pala, Heidie TadeoTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On today's date, Licensing Program Manager (LPM) Alisa Ortiz, and Licensing Program Analysts (LPAs) Dwayne Mason Jr. William Vanegas and Samer Haddadin met with Licensee Representatives Gary Tadeo and Peppi Pala on this day for the purpose of discussing potential facility change of ownership. Heidie Tadeo, Facility Administrator, was also present.

During the meeting all participants were reminded of Regulations pertaining to Accountability of Licensee and the expectations regarding change of ownership applications.

The following was discussed:

  • Licensee's responsibilities of facility oversight
  • Update on facility's possible change of application status


During the meeting, both Licensee Representatives were provided with possible options for updates to administrative organization and/or change of ownership. Both licensees will communicate any changes or updates to the Department.

No deficiency are being cited per Title 22 at this time.

An exit interview was conducted with Licensees. A copy of this report, LIC 809, was provided to Licensee during the visit.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 10/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/09/2024
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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