Country Inn

Type of visit: Case Management - Annual Continuation

At approximately 10:30 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual continuation inspection and met with Rolando Macaraig, Administrator. Facility is a Residential Care Facility for the Elderly (RCFE) with fourteen (14) residents in care, all of whom were present during today's inspection. Facility has a Dementia Care Plan and a Hospice waiver for three (3). At approximately 11:00 AM, LPA initiated a tour of the community with Administrator and observed the following: Facility is a one story building, was a comfortable temperature, and passageways were free from obstructions. Water temperature in residents' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of paper products available to residents. Administrator agrees to ensure all closets containing cleaning supplies and other items that could pose a risk remain inaccessible to residents in care at all times. The community has at least two days of perishable food and one week of non-perishable foods. Medications were centrally stored and administrator agrees to ensure they are secured and inaccessible to residents at all times. There are covered seating areas and outdoor space for activities. LPA observed residents watching TV, resting in their rooms, and one playing cards on their computer. Facility has internet service and an internet access device available for resident use. Facility's telephone was observed operational during inspection. The community's fire extinguishers were observed charged and were last serviced 12/2025. Sprinklers and Smoke and Carbon Monoxide detectors were last inspected by a third party vendor 08/2022, which passed in all categories. Administrator agrees to ensure facility conducts emergency/disaster drills no less than quarterly in order to operate in compliance with regulation. continued on LIC809C... Continued from LIC809... LPA observed facility's infection control plan and emergency disaster plan which was last updated 01/2023. LPA observed a supply of PPE, emergency supplies, flashlights and a first aid kits throughout the community. Facility has multiple portable backup generators and an external defibrillator for emergency preparedness. At approximately 1:00 PM, LPA reviewed five (5) resident records and five (5) staff records. Three (3) of five (5) residents' records were missing a current appraisal needs and services plan (see LIC809D), and two (2) of five (5) residents' records were missing a current physician's report as required for those residents per regulation, (see LIC809D). One (1) of five (5) staff records reviewed were missing proof of the required intial 40 hours of training, and four (4) of five (5) were missing proof of the required 20 hours of annual training. One (1) of five (5) staff files reviewed was missing a job application, and one (1) of five (5) was also missing a physician's health screening and proof of CPR/FA certification, (see LIC809D). Medication records were reviewed and were observed managed and stored in compliance with regulation. Facility works with residents and their families to coordinate medical and dental visits as well as transportation to and from appointments. Facility does not manage P&I cash resources but has a bond. Updated copies of the following documents are to be submitted to CCL within 30 days of this visit: -LIC500 - Personnel Report (updated) -LIC610D - Emergency Disaster Plan (updated) -A copy of facility's current liability insurance -Emergency Disaster Drill Conducted (current) Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, or repeat violations within a 12 month period, may result in a civil penalty assessment. Exit interview conducted with Administrator whose signature on form confirms receipt of documents. Appeal rights provided.the state’s words, verbatim · CDSS document, Jan 8, 2026

The state marks this report as 7 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

At approximately 3:45 PM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and met with Mercedita Lavarias, Designated Responsible Party (DRP). Administrator was contacted via telephone and gave permission to proceed with today's visit without them. Facility is a Residential Care Facility for the Elderly (RCFE) with fourteen (14) residents in care, all of whom were present during today's inspection. Facility has a Dementia Care Plan and a Hospice waiver for three (3). LPA obtained a copy of the current staff and resident rosters. LPA will return at a later date to complete this inspection. Exit interview conducted with DRP whose signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jan 7, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPAs) Stevenson and Arnhold arrived unannounced at approximately 9:15 AM to conduct a 1-Year Required Annual Inspection. LPAs was met by administrator Rolondo Macaraig and assistant administrator Shannon Gayski. There were 12 residents in care. At approximately 9:45am LPAs and care staff toured facility together to ensure health and safety of residents in care. Areas toured included but not limited to: common areas, resident bedrooms, kitchen, common restrooms, outdoor storage areas including locked and fenced pool area. LPAs observed the facility to be a comfortable temperature, clean, odor-free, numerous opportunities for activities were noted and underway with staff. Bathrooms were noted to have the necessary grab bars, non-skid flooring or shower chairs. LPAs observed each bedroom to have the necessary furnishings with working lights and windows with screens. Facility has a 2-day perishable and a 7-day non-perishable amounts of food and sharps were locked. Hot water temperature was measured within the required range between 105 and 120F. LPAs observed several charged fire extinguishers, hard wired smoke, and carbon monoxide detectors throughout the facility. Meds were centrally stored and locked and in good order. LPAs observed the first aid kit to be complete and ready for use. LPA reviewed a total of five (5) of 12 residents' files and five (5) staff files. Resident files reviewed, contained all the required documentation. 5 of 5 staff files reviewed did not contain evidence of completed annual training. LPAs were given update copies of Personnel Report (LIC500, Affidavit regarding cash resources LIC400, well bacterial testing, updated certificate of Liability Insurance) LPAs requested current lease agreement to be submitted to CCL within 30 days from this visit. Continued on 809-C Continued from 809..... Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Appeal rights were given This report was reviewed with and appeal rights were given to administrator Rolando Macaraigthe state’s words, verbatim · CDSS document, Feb 7, 2025

Type of visit: Required - 1 Year

At approximately 10:25 AM Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced to conduct an annual required inspection and met with Assistant Administrator, Shannon Gayski. LPA and Assistant Administrator discussed the purpose of the visit. LPA initiated a tour of the facility around 11:00 AM and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Water temperature in sinks accessible to residents measured at 114, 109 and 116 degrees F which are within the range of 105 to 120 degrees F allowed per regulation. Extra hygiene products and linens were available. Cleaning supplies were stored in a locked cabinet outside. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. Medications were centrally stored and locked. Emergency food and water supplies are stored in an outdoor storage shed. Personal Protective Equipment is stored in back storage room. Fire extinguishers were last serviced December 2023. Facility has combination Smoke/ Carbon Monoxide detectors that were tested and operational during visit. Most recent fire/disaster drill was conducted 12/01/2023. 5 staff files and 5 resident files were reviewed. Staff have required First Aid and CPR certificates. Training records were reviewed. Administrator Certificate for Administrator, Rolando Macaraig (6012447740), is up to date and expires 03/24/2024. Medications and medication records were reviewed. Continued on LIC809 Continued from LIC 809 Administrator to submit updates of the following documents by 02/17/2024: LIC 500 Personnel Summary Copy of Liability Insurance LIC 9020 Register of Residents Emergency Disaster Plan (If changes) Infection Control Plan (If changes) No deficiencies cited during inspection. Exit interview conducted. Copy of report discussed and provided to Assistant Administrator. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jan 17, 2024