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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 372004630
Report Date: 11/18/2024
Date Signed: 11/18/2024 02:11:12 PM

Document Has Been Signed on 11/18/2024 02:11 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:COUNTRY CLUB GUEST HOMEFACILITY NUMBER:
372004630
ADMINISTRATOR/
DIRECTOR:		RAMIREZ, JULIEFACILITY TYPE:
740
ADDRESS:25533 RUA MICHELLETELEPHONE:
(760) 747-0957
CITY:ESCONDIDOSTATE: CAZIP CODE:
92026
CAPACITY: 30CENSUS: 27DATE:
11/18/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Licensee, Julie RamirezTIME VISIT/
INSPECTION COMPLETED:
02:25 PM
NARRATIVE
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On 11/18/2024, Licensing Program Analyst (LPA), Janette Romero arrived unannounced to address a deficiency discovered during investigation of complaint control number 18-AS-20241113162414. LPA met with Licensee, Julie Ramirez who was informed of the purpose of the visit.

During the investigation, Staff 1 (S1) was interviewed and reported on several occasions, they have physically showered Resident 1 (R1) after R1 verbalized their refusal to shower. S1 reported R1 attends day program and they believed R1 was required to shower on their scheduled shower days. Licensee Ramirez reported the facility does not currently document resident shower refusals. S1 also reported they gave R1 the option to shower or stay home from day program. The facility will be cited.

An exit interview was conducted where a copy of this report was reviewed and provided to Licensee Ramirez along with Confidential Names list (LIC 811) and Appeal Rights.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2024
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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Document Has Been Signed on 11/18/2024 02:11 PM - It Cannot Be Edited


Created By: Janette Romero On 11/18/2024 at 01:58 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: COUNTRY CLUB GUEST HOME
FACILITY NUMBER: 372004630

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/22/2024
Section Cited
CCR
87468.1(a)(3)

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(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination.
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Licensee reported they will conduct an in-service staff training regarding residents' personal rights and develop a log to document residents' shower refusals. Proof of correction to be submitted to LPA by POC due date.
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Based on interviews conducted, S1 showered R1 on several ocassions despite R1 verbalizing their refusal to shower. This poses a potential personal rights risk to clients in care.
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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.
SUPERVISOR'S NAME:Tricia Danielson
LICENSING EVALUATOR NAME:Janette Romero
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2024


LIC809 (FAS) - (06/04)
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