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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881645
Report Date: 10/15/2024
Date Signed: 10/15/2024 10:12:29 AM

Document Has Been Signed on 10/15/2024 10:12 AM - 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:OUR COUNTRYSIDE RESORTFACILITY NUMBER:
331881645
ADMINISTRATOR/
DIRECTOR:		MAHAN, ELIZABETHFACILITY TYPE:
740
ADDRESS:18111 HAINES STREETTELEPHONE:
(951) 657-3557
CITY:PERRISSTATE: CAZIP CODE:
92570
CAPACITY: 36CENSUS: 16DATE:
10/15/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Applicant, Robert RamosTIME VISIT/
INSPECTION COMPLETED:
10:20 AM
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Licensing Program Analysts (LPA) Janette Romero and Debbie Palacios made an announced visit to the facility to conduct a pre-licensing evaluation. LPAs met with Applicant, Robert Ramos and Administrator, Elizabeth Mahan whose administrator’s certificate expires on 2/28/2026.

LPA Palacios toured the facility with Administrator Mahan. Indoor and outdoor passageways are free of obstruction. There are no bodies of water on the premises. LPA confirmed the fire department tested the facility's smoke alarms/carbon monoxide detectors during the fire inspection on 10/2/2024. The facility's fire extinguishers were last serviced on 8/19/2024. The facility has a central heating and air conditioning system installed with a central panel located in the hallway to control entire facility. LPAs toured a sample of resident bedrooms and found them to be adequately furnished with a bed, chair, lighting and closet storage. LPAs toured a sample of the resident bathrooms and observed them to have a working toilet, wash basin, with toilet paper, paper towels, and soap readily available. Bathrooms with showers have non-skid mats and grab bars in the showers. Facility has a barber room and activity room and an outside patio to have outdoor activities. LPAs tested the hot water temperatures is some of the bathrooms, which measured at 111.05, and 108.9-degrees Fahrenheit. LPAs toured the kitchen and observed the facility has a two-day supply of perishable foods and seven-day supply of non-perishable food items. Knives/sharp instruments will be secured in the kitchen. Medications are centrally stored in a locked cabinet in the medication room. Cleaning solutions and disinfectants are secured in a locked laundry room. The facility has a confidential storage area designated for staff and resident records.

During today's visit, LPA did not observe any issues or concerns, and there are no corrections required. Applicant Ramos and Administrator Mahan are scheduled to attend the COMPIII tomorrow, 10/16/2024 at the Riverside Regional Office. Final approval of licensure will be granted by the CAB analyst. An exit interview was conducted, and a copy of this report was reviewed and provided to Applicant Ramos.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE: DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2024
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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