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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881645
Report Date: 07/14/2025
Date Signed: 07/14/2025 04:40:37 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/10/2025 and conducted by Evaluator Abdoulaye Zerbo
COMPLAINT CONTROL NUMBER: 18-AS-20250710105402
FACILITY NAME:OUR COUNTRYSIDE RESORTFACILITY NUMBER:
331881645
ADMINISTRATOR:MAHAN, ELIZABETHFACILITY TYPE:
740
ADDRESS:18111 HAINES STREETTELEPHONE:
(951) 657-3557
CITY:PERRISSTATE: CAZIP CODE:
92570
CAPACITY:36CENSUS: 31DATE:
07/14/2025
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Administrator Elizabeth MahanTIME COMPLETED:
04:50 PM
ALLEGATION(S):
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Licensee does not ensure that staff have required medication training
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Abdoulaye Zerbo conducted an unannounced visit to the facility to initiate a complaint investigation. LPA was greeted and granted entrance by Administrator Elizabeth Mahan. LPA identified himself and discussed the purpose of the visit.
It was alleged Licensee does not ensure that staff have required medication training. Concerns were made about staff having expired medication training certificates. LPA reviewed records and interviewed staff, information obtained revealed that S1 and S2 have expired medication training certificates since April 2025
Based on observations, interviews and records review the allegation of Licensee does not ensure that staff have required medication training is substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.
An exit interview was conducted where a copy of this report, 9099D, appeal rights, was reviewed and provided to Administrator Elizabeth Mahan.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2025
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 18-AS-20250710105402
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 RESORT
FACILITY NUMBER: 331881645
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/18/2025
Section Cited
HSC
1569.69(e)(2)(D)
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1569.69
Employees assisting residents with self-administration of medication; training requirements:
(e)(2)(D)Possession of a license as a medical professional.
This requirement is not met evidenced by:
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Licensee agreed to send the renewed medication certificate by POC due date
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Based records review, observation and interview , the licensee did not comply with the section cited above in 2 out of 4 staff having an expired medication training certificate.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2