<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530286
Report Date: 03/12/2025
Date Signed: 03/12/2025 11:10:20 AM

Document Has Been Signed on 03/12/2025 11:10 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:COUNTRY CLUB CAREFACILITY NUMBER:
365530286
ADMINISTRATOR/
DIRECTOR:		OGANESIAN, ROSIEFACILITY TYPE:
740
ADDRESS:14675 TIGER TAIL RDTELEPHONE:
(323) 491-9001
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92307
CAPACITY: 6CENSUS: 0DATE:
03/12/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Rosie Oganesian, AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 03/12/2025, Licensing Program Analyst (LPA) Becky Mann conducted an announced visit to the facility for purpose of Prelicensing evaluation. LPA met with Administrator Rosie Oganesian. An initial application to operate a Residential Care Facility for the Elderly (RCFE) was submitted to the Central Applications Bureau (CAB) on 08/01/2024 for a total capacity of six (6), five (5) Non-ambulatory and one (1) bedridden. LPA observed the following:

Structure:
Facility has five (5) bedrooms, three (3) bathrooms, living room, dining area and kitchen. There's an attached garage.

Bedrooms:
Each resident bedrooms accommodate any non-ambulatory resident. All resident bedrooms were furnished with bed, mattress, chair, closet, linens, adequate lighting and an operable smoke detectors.

Bathrooms:
The three (3) resident/staff bathrooms have a working toilet, wash basin, and shower. LPA verified water temperature was measured between 107 and 118 degrees Fahrenheit.

Kitchen/Laundry:
An adequate supply of dishes, glasses, utensils, pots, and pans were observed. Knives/sharp instruments were secured in a locked drawer. Refrigerator/freezer were in working condition. There is sufficient storage for perishable food. Laundry room with washer and dryer was in the laundry area. Laundry detergents and cleaning supplies were observed in the laundry room in locked cabinets.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Becky Mann
LICENSING EVALUATOR SIGNATURE: DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/12/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: COUNTRY CLUB CARE
FACILITY NUMBER: 365530286
VISIT DATE: 03/12/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Living/Family room:
There's a living/family room with adequate seating for all residents and a working TV.

Linens and Hygiene Supplies:
An adequate supply of linens were stored in the facility.

Yards/Outside:
Patio furniture for outdoor seating observed. Self-latching handle gate on left side of the house that leads into the backyard. All outdoor pathways were free of obstructions.

Emergency Phone Numbers, and Exit Plan:
Facility sketch was observed posted in the dining area.

General items:


Two (2) fire extinguisher were charged. The smoke detectors and carbon monoxide detectors were tested and were observed to be in working order. Resident records and staff records will be stored in a locked cabinet in the lounge area. First Aid kit with required components and locked area for medication storage was observed. LPA observed a facility phone which is operational.

There is enough Emergency water supply and the required 72-hour emergency food supply for residents and staff available at the facility. Component III was completed on this day.

The facility was evaluated in accordance with the California Code of Regulations (CCR), Title 22, Division 6, Chapters 1 and 6 to ensure the health and safety of residents in care. Facility is ready for licensure.

An exit interview was conducted, and a copy of this report, LIC809 and LIC809C was discussed and provided to Administrator Rosie Oganesian.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Becky Mann
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025
LIC809 (FAS) - (06/04)
Page: 2 of 2