Country Club Senior Home Care

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Hanna Gough made an unannounced visit to the facility to conduct the required annual inspection. LPA was greeted and granted entry by staff. LPA met with Administrator (AD) Heidie Tadao and discussed the purpose of the visit. The facility currently has six residents in care. The facility is a one story home with six resident bedrooms, eight bathrooms, one staff bedroom, kitchen, living room, dining room, staff office, laundry room and attached two car garage. The facility appears clean, safe and sanitary. LPA observed all resident rooms to have the required components and furnishings. LPA observed the restrooms to be stocked with toilet paper, paper towels and nonslip mats in the shower. LPA tested the water in the resident restrooms to be between 109.5 and 113 degrees Fahrenheit. LPA observed a clean supply of linens in the hall by the back door for resident use. LPA observed the kitchen to be clean and free of vermin. LPA observed the emergency food supply to be stored in the kitchen pantry. LPA observed a two day perishable and seven day nonperishable food supply on hand. LPA observed the knives and sharps to be in a locked kitchen cabinet making them inaccessible to residents in care. LPA observed toxins and chemicals to be locked under the kitchen sink and in a locked cabinet located in the laundry room making them inaccessible to residents in care. LPA observed a fire extinguisher by the laundry room charged and with a service date of October 24, 2025. LPA observed the staff bedroom to be unlocked with no objects or medications accessible to residents. LPA observed the centrally stored medication cart to be locked and stored in the staff office making it inaccessible to residents in care. LPA observed the garage to be locked and made inaccessible to residents in care. LPA observed food storage in the garage as well as the emergency water supply. LPA observed the backyard to be free of debris and obstructions. LPA and AD tested the carbon monoxide detector and fire alarms and they were found to be operational. Continue on LIC809C LPA reviewed staff files and observed the staff 20 hour annual training is incomplete. LPA reviewed resident files and no discrepancies were observed. LPA observed resident medications and no discrepancies were observed. LPA observed the last fire drill was conducted on February 2, 2026. All staff present are background cleared and associated to the facility. Based on today’s observations one technical violation is being noted per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report along with the technical violation were provided at the time of the visit.the state’s words, verbatim · CDSS document, Feb 3, 2026

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

On February 25th, 2025 Licensing Program Analyst (LPA) William Vanegas made an unannounced inspection for the purposes of an annual inspection. Upon arrival LPA Vanegas was greeted and granted entry to the facility by Care Giver (CG) Perlita Abilar and explained the purpose of the visit. LPA Vanegas began a tour of the facility and observed the following. This is a one storied home with seven bedrooms one of which is a staff room and six of which are resident rooms, there are seven bathrooms; with an attached two car garage. LPA Vanegas observed kitchen area to be clean and free of debris. LPA Vanegas observed there to be a gas stove, microwave, dish washer, and a washer and dryer. All appeared to be in good repair and tested operational. LPA Vanegas observed a two day supply of perishable food and a seven day supply of non-perishable food. LPA Vanegas observed a sufficient amount of emergency water as well. LPA Vanegas observed resident rooms to be clean and in good repair. LPA Vanegas observed client rooms to have all required furnishings such as a chest drawer, a bed, a lamp, and clean linens in good repair meaning no strains or tears. LPA Vanegas observed resident restrooms to have all required furnishings such as grab bars, slip resistant matts, and shower chair. LPA Vanegas observed water faucets and toilets to be functional. Water temperature tested between 115.8 and 120.3 degrees. LPA Vanegas observed fire extinguisher to be fully charged and up to date. LPA Vanegas observed all carbon monoxide and smoke detectors to be operational and in good repair. LPA Vanegas observed all medications, toxins, and sharps to be locked away and inaccessible to residents in care. LPA Vanegas observed outside of the facility to be clean and free of any obstructions along emergency exit routes. CONTINUED ON LIC809C LPA Vanegas reviewed four staff records, and six resident records. All records (Staff and Resident) had all required documentation and all staff training was up to date. LPA Vanegas reviewed medications with AD Gary Tadeo and per LPA Vanegas review, all medications are being documented and administered per physicians orders. based on today's observations no deficiencies will be cited per title 22 chapter six of the California Code Of Regulations. An exit interview was conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Feb 25, 2025

Type of visit: Office

On today's date, Licensing Program Manager (LPM) Alisa Ortiz, and Licensing Program Analysts (LPAs) Dwayne Mason Jr. William Vanegas and Samer Haddadin met with Licensee Representatives Gary Tadeo and Peppi Pala on this day for the purpose of discussing potential facility change of ownership. Heidie Tadeo, Facility Administrator, was also present. During the meeting all participants were reminded of Regulations pertaining to Accountability of Licensee and the expectations regarding change of ownership applications. The following was discussed: Licensee's responsibilities of facility oversight Update on facility's possible change of application status During the meeting, both Licensee Representatives were provided with possible options for updates to administrative organization and/or change of ownership. Both licensees will communicate any changes or updates to the Department. No deficiency are being cited per Title 22 at this time. An exit interview was conducted with Licensees. A copy of this report, LIC 809, was provided to Licensee during the visit.the state’s words, verbatim · CDSS document, Oct 9, 2024

Allegation investigated: Facility does not have a qualified Administrator Facility has not notified Licensing of their new Administrator

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Dwayne Mason Jr. for the purpose of initiating the investigation into the above-mentioned complaint allegations. LPA met with Administrator (AD1) Gary Tadeo and discussed the purpose of the inspection. Administrator (AD2) Heidie Tadeo and Licensee (L) Peppi Pala joined the inspection as well. LPA conducted interviews with Administrators and Licensee. LPA obtained copies of the Personnel Report, Resident roster, Administrator Certification for AD1 and AD2, receipt for registered mail sent to the Department on 6/18/2024 and proof of delivery indicating the notification was delivered on 6/19/2024. LPA observed the address the notification was sent to was incorrect. LPA provided the facility with the correct address and advised them to continue reaching out the Department if they do not receive any communication in return. (continued on LIC9099-C) Unsubstantiated (continued from LIC9099) Based on interviews conducted and records reviewed, LPA determined the facility replaced their Administrator with a qualified candidate within 30 days as required by Title 22 Regulations. LPA determined that, although the facility sent the notification to the incorrect address, they otherwise took appropriate action to notify the Department within the 30 days as required by Title 22 Regulations. Based on interviews conducted and records reviewed, LPA determined that due the facility's actions following the resignation of their previous Administrator and due to the facility having no similar previous citations, there is insufficient evidence to support the allegation. Although the allegation may have happened or is valid; there is not a preponderance of evidence to prove that the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted, and this report was reviewed with facility staff. A copy of this LIC-9099 was provided to the facility.the state’s words, verbatim · CDSS document, Sep 27, 2024 · control 22-AS-20240918141952

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Claudia Gutierrez made an announced visit to the facility for purpose of conducting a pre-licensing inspection. LPA met with designated Administrator (AD) Ma Teresa Abuda, Licensee Gary Tadeo and Peppi Pala, Assistant Administrator (AAD) Heidi Tadeo and Consultant Kian Pascual. An application to operate an Residential Care Facility for the elderly (RCFE) for (6) capacity, (0) ambulatory, (0) non-ambulatory, and (6) bedridden residents was received by CCL on 9/20/2023. Structure: The facility is a one-story house with six resident bedrooms, one staff bedroom, two full size bathrooms, six half bathrooms, a living room, a kitchen, a dining room, an activity room/staff office, a laundry room, and attached two car garage. LPA observed the See Something, Say Something poster (PUB 475) in the facility mounted on the wall in the entranceway. There is a backyard with an exit gate each on one side of the house. There is a shaded seating area and LPA did not observe any obstacles or hazards in the backyard. Resident Bedrooms All resident bedrooms had the required furnishings. LPA observed all beds had linens and blankets. Signal system There is no signal system. Toxins: All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residents and will be stored and locked in the laundry room. Pool/Jacuzzi: No bodies of water were observed. Medications, First-Aid Kit & Book: Medication will be stored in a locked medicine cart. First aid kit is stored in the staff office. The first aid kit has all the required elements. Resident & Staff Files: Records will be kept in a locked file cabinet. Fire Extinguisher: Fire extinguisher is fully charged with service tag dated 9/26/2023. Reading Material, Games, Equipment & Materials: The facility has reading books, activity books, arts and crafts supplies, board games, puzzles, and other recreational materials for resident use stored in the activity room. Fire clearance: Was approved by a fire inspector of Orange County Fire Authority on 11/07/2023. Special conditions noted, “Bedrooms #3-7 approved for bedridden clients.” Component III: Conducted at the Pre-Licensing visit, information provided about how to operate the facility within compliance and reporting requirements. Bedrooms Staff: There is one staff bedroom. Bathrooms: All bathrooms have working plumbing. Hot water measured between 115.8- and 118.9-degrees Fahrenheit. Linens & Hygiene Supplies: A supply of extra linen was stored in the closet of each resident bedroom. Emergency Phone Numbers, Exit Plan & Menu: Posted and available, means of exiting, and emergency phone numbers. Food menu is posted and available. Food Service: A supply of 2-day perishable and 7-day of non-perishable food was observed and will be maintained on hand. Smoke Detectors: Smoke detectors and carbon monoxide detectors tested operational. Appliances: Gas burner stove, dishwasher, refrigerator, microwave, washer, and dryer are operational. Licensees and designated AD was notified that the final application approval will be issued by the Centralized Applications Bureau in Sacramento. An exit interview was conducted and a copy of this report was provided to Licensee.the state’s words, verbatim · CDSS document, Feb 14, 2024

Type of visit: Office

Facility Type: RCFE Application Type: Initial Capacity: 6 Interview Method: Telephone interview On 1/25/2024, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Jan 25, 2024