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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006428
Report Date: 02/25/2025
Date Signed: 02/25/2025 04:33:14 PM

Document Has Been Signed on 02/25/2025 04:33 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 RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:COUNTRY CLUB SENIOR HOME CAREFACILITY NUMBER:
306006428
ADMINISTRATOR/
DIRECTOR:		TADAO, HEIDIEFACILITY TYPE:
740
ADDRESS:8271 COUNTRY CLUB DRIVETELEPHONE:
(909) 900-6064
CITY:BUENA PARKSTATE: CAZIP CODE:
90621
CAPACITY: 6CENSUS: 6DATE:
02/25/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Gary TadeoTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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On February 25th, 2025 Licensing Program Analyst (LPA) William Vanegas made an unannounced inspection for the purposes of an annual inspection. Upon arrival LPA Vanegas was greeted and granted entry to the facility by Care Giver (CG) Perlita Abilar and explained the purpose of the visit. LPA Vanegas began a tour of the facility and observed the following.

This is a one storied home with seven bedrooms one of which is a staff room and six of which are resident rooms, there are seven bathrooms; with an attached two car garage. LPA Vanegas observed kitchen area to be clean and free of debris. LPA Vanegas observed there to be a gas stove, microwave, dish washer, and a washer and dryer. All appeared to be in good repair and tested operational. LPA Vanegas observed a two day supply of perishable food and a seven day supply of non-perishable food. LPA Vanegas observed a sufficient amount of emergency water as well.

LPA Vanegas observed resident rooms to be clean and in good repair. LPA Vanegas observed client rooms to have all required furnishings such as a chest drawer, a bed, a lamp, and clean linens in good repair meaning no strains or tears. LPA Vanegas observed resident restrooms to have all required furnishings such as grab bars, slip resistant matts, and shower chair. LPA Vanegas observed water faucets and toilets to be functional. Water temperature tested between 115.8 and 120.3 degrees.

LPA Vanegas observed fire extinguisher to be fully charged and up to date. LPA Vanegas observed all carbon monoxide and smoke detectors to be operational and in good repair. LPA Vanegas observed all medications, toxins, and sharps to be locked away and inaccessible to residents in care. LPA Vanegas observed outside of the facility to be clean and free of any obstructions along emergency exit routes.

CONTINUED ON LIC809C
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: William Vanegas
LICENSING EVALUATOR SIGNATURE: DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/25/2025
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: COUNTRY CLUB SENIOR HOME CARE
FACILITY NUMBER: 306006428
VISIT DATE: 02/25/2025
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LPA Vanegas reviewed four staff records, and six resident records. All records (Staff and Resident) had all required documentation and all staff training was up to date. LPA Vanegas reviewed medications with AD Gary Tadeo and per LPA Vanegas review, all medications are being documented and administered per physicians orders.

based on today's observations no deficiencies will be cited per title 22 chapter six of the California Code Of Regulations. An exit interview was conducted and a copy of this report was left at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: William Vanegas
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025
LIC809 (FAS) - (06/04)
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