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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881645
Report Date: 10/23/2025
Date Signed: 10/23/2025 09:43:52 PM

Document Has Been Signed on 10/23/2025 09:43 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
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: 31DATE:
10/23/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Elizabeth MahanTIME VISIT/
INSPECTION COMPLETED:
05:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Abdoulaye Zerbo conducted an unannounced visit for a required annual inspection. The LPA was greeted by Administrator Elizabeth Mahan, notified them of the purpose for the visit and was allowed to enter the facility to conduct the inspection.
Facility Overview: The facility is a single- story building with 17 residents' bedrooms, 19 bathrooms, a dinning room, a recreation room, a medication room, a kitchen, a laundry room, an office, and an outdoor area. There is no gated pool and there are no firearms on the premises.
Infection Control: LPA observed that hygiene and cleaning supplies were available for regular facility maintenance. The facility’s infection control plan was reviewed and found to meet department's requirements.
Physical Plant: The physical plant, including floors, windows, and doors, was clean and well maintained. Fixtures and furniture were in good repair. Laundry equipment was in good working condition. Sharp and dangerous objects were securely locked in the kitchen area and inaccessible to residents in care. The carbon monoxide detectors were operable. LPA observed fire extinguisher to be in compliance with the department's requirements and with an expiration date of 08-04-2026. The water temperature was tested at 130.4 F. Citation with be issued

Continued 809-C......

NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Abdoulaye Zerbo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/23/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: OUR COUNTRYSIDE RESORT
FACILITY NUMBER: 331881645
VISIT DATE: 10/23/2025
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Care & Supervision/Administration: Adequate staff were present to supervise residents during the visit. The Administrator holds a current administrator’s certificate with the expiration date of 02-28-26 and CPR certification with the expiration date of 08-01-26.


Record Review and Resident/Staff Files: LPA reviewed files for 4 staff members, confirming criminal clearance, updated training, and health screening. 3 residents' files were reviewed and contained all the required documentation. LPA observed first kit to be available for the residents in care. The residents and staff files were kept locked and inaccessible to unauthorized individuals.

Health-Related Services/Incidental Medical Services: All residents' medications were securely locked in a the medication room. LPA reviewed medications for 3 residents and found discrepancies with records and the medication being administered. Citation will be issued.

Disaster Preparedness: LPA reviewed the facility’s emergency and disaster plan, including documentation of the last emergency drill conducted on 10-05-2025, which met the department's requirements. All facility exits were clear of obstructions.


Deficiencies were cited during the visit. An exit interview was conducted, during which this report, the 809 D and the appeal rights were reviewed, and a copy was provided to Administrator Elizabeth Mahan
NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Abdoulaye Zerbo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/23/2025 09:43 PM - It Cannot Be Edited


Created By: Abdoulaye Zerbo On 10/23/2025 at 04:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 10/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA measured water temperature in 3 different locations averaging 130.0 degrees Fahrenheit, which poses a potential health, safety or personal rights risk to persons in care..
POC Due Date: 10/30/2025
Plan of Correction
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Licensee agreed to adjust the water temperature and record the reading for seven(7) days and send proof to LPA by POC due date
Type B
Section Cited
CCR
87465(d)
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration provided all of the following requirements are met:
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 3 of 3 residents that were missing medication, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/30/2025
Plan of Correction
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Licensee agreed to conduct a training on medication administration requirements and provide a copy of the sign in sheet and the material(s) used for the training.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Anthony Perez
NAME OF LICENSING PROGRAM MANAGER:
Abdoulaye Zerbo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2025


LIC809 (FAS) - (06/04)
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