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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 372004630
Report Date: 08/21/2024
Date Signed: 12/27/2024 11:20:35 AM

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
08/14/2024 and conducted by Evaluator Janette Romero
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20240814162626
FACILITY NAME:COUNTRY CLUB GUEST HOMEFACILITY NUMBER:
372004630
ADMINISTRATOR:RAMIREZ, JULIEFACILITY TYPE:
740
ADDRESS:25533 RUA MICHELLETELEPHONE:
(760) 747-0957
CITY:ESCONDIDOSTATE: CAZIP CODE:
92026
CAPACITY:30CENSUS: 27DATE:
08/21/2024
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Caregiver, Claras Aguas TIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Staff did not provide resident a statement of fees or payments
INVESTIGATION FINDINGS:
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On 12/27/2024, Licensing Program Analyst (LPA), Janette Romero made an unannounced visit to the facility to deliver amended findings regarding the allegation listed above. LPA met with Caregiver, Claras Aguas who was informed of the of the purpose of the visit. LPA communicated with Licensee, Julie Ramirez over the phone who was also informed of the purpose of the visit.

It was alleged the facility is managing Resident 1's (R1's) finances and did not provide them with receipts or statements of fees. LPA toured the facility, conducted interviews and obtained copies of pertinent records. LPA reviewed R1's Physician's Report (LIC602A) dated 8/17/2023, which indicates R1 does not have the capacity to manage their own cash resources. LPA also reviewed two (2) Resident Appraisals (LIC603s) for R1 dated 3/1/2015 and 6/14/2019, which list assistance with managing cash resources as a service needed. LPA reviewed R1's admission agreement dated 3/1/2015, which also indicates the facility will maintain and supervise R1's cash resources. R1's checkbook is safeguarded by Administrator, Kevin Ramirez in the staff office. Administrator, Melanie Cuaresma corroborated this information.

*This is an amended version of the original report
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2024
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 4
Control Number 18-AS-20240814162626
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: COUNTRY CLUB GUEST HOME
FACILITY NUMBER: 372004630
VISIT DATE: 08/21/2024
NARRATIVE
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Administrator Cuaresma was interviewed and reported the facility manages R1's finances and has never provided R1 with receipts for cash resources or monthly rent paid to the facility. Administrator Cuaresma reported the facility keeps a record of R1's safeguarded cash resources and was unaware they had to provide R1 with receipts. R1 was interviewed and reported their finances are managed by the facility and they have not received receipts for rent paid or statements of fees. Based on LPA’s interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099 D. An exit interview was conducted and a copy of this report was provided to Administrator Cuaresma along with a Confidential Names List (LIC811) and Appeal Rights.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 18-AS-20240814162626
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: COUNTRY CLUB GUEST HOME
FACILITY NUMBER: 372004630
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/21/2024
Section Cited
CCR
87217(b)
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87217(b) The licensee shall give the residents receipts for all such articles or cash resources.
This requirement was not met as evidenced by:
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During LPA's visit, Administrator Cuaresma had a physical receipt book, featuring a white originals and canary duplicates, delivered to the facility. Administrator stated the facility will provide R1 with the original white receipt and keep the canary duplicate for their records.
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A complaint investigation revealed the facility was managing R1's finances and providing them with receipts for monthly rent or cash resources. This poses a potential health/safety/personal rights to residents in care.
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Administrator also stated the facility will use the Department's LIC405 form in place of their log. POC met.
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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: Tricia Danielson
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4