Our Countryside Resort

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Abdoulaye Zerbo conducted an unannounced visit for a required annual inspection. The LPA was greeted by Administrator Elizabeth Mahan, notified them of the purpose for the visit and was allowed to enter the facility to conduct the inspection. Facility Overview: The facility is a single- story building with 17 residents' bedrooms, 19 bathrooms, a dinning room, a recreation room, a medication room, a kitchen, a laundry room, an office, and an outdoor area. There is no gated pool and there are no firearms on the premises. Infection Control: LPA observed that hygiene and cleaning supplies were available for regular facility maintenance. The facility’s infection control plan was reviewed and found to meet department's requirements. Physical Plant: The physical plant, including floors, windows, and doors, was clean and well maintained. Fixtures and furniture were in good repair. Laundry equipment was in good working condition. Sharp and dangerous objects were securely locked in the kitchen area and inaccessible to residents in care. The carbon monoxide detectors were operable. LPA observed fire extinguisher to be in compliance with the department's requirements and with an expiration date of 08-04-2026. The water temperature was tested at 130.4 F. Citation with be issued Continued 809-C...... Care & Supervision/Administration: Adequate staff were present to supervise residents during the visit. The Administrator holds a current administrator’s certificate with the expiration date of 02-28-26 and CPR certification with the expiration date of 08-01-26. Record Review and Resident/Staff Files: LPA reviewed files for 4 staff members, confirming criminal clearance, updated training, and health screening. 3 residents' files were reviewed and contained all the required documentation. LPA observed first kit to be available for the residents in care. The residents and staff files were kept locked and inaccessible to unauthorized individuals. Health-Related Services/Incidental Medical Services: All residents' medications were securely locked in a the medication room. LPA reviewed medications for 3 residents and found discrepancies with records and the medication being administered. Citation will be issued. Disaster Preparedness: LPA reviewed the facility’s emergency and disaster plan, including documentation of the last emergency drill conducted on 10-05-2025, which met the department's requirements. All facility exits were clear of obstructions. Deficiencies were cited during the visit. An exit interview was conducted, during which this report, the 809 D and the appeal rights were reviewed, and a copy was provided to Administrator Elizabeth Mahanthe state’s words, verbatim · CDSS document, Oct 23, 2025

Allegation investigated: Licensee does not ensure that staff have required medication training

Licensing Program Analyst (LPA) Abdoulaye Zerbo conducted an unannounced visit to the facility to initiate a complaint investigation. LPA was greeted and granted entrance by Administrator Elizabeth Mahan. LPA identified himself and discussed the purpose of the visit. It was alleged Licensee does not ensure that staff have required medication training. Concerns were made about staff having expired medication training certificates. LPA reviewed records and interviewed staff, information obtained revealed that S1 and S2 have expired medication training certificates since April 2025 Based on observations, interviews and records review the allegation of Licensee does not ensure that staff have required medication training is substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. An exit interview was conducted where a copy of this report, 9099D, appeal rights, was reviewed and provided to Administrator Elizabeth Mahan. Substantiatedthe state’s words, verbatim · CDSS document, Jul 14, 2025 · control 18-AS-20250710105402

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.69(e)(2)(D) · Plan of correction due date: Jul 18, 2025

1569.69 Employees assisting residents with self-administration of medication; training requirements: (e)(2)(D)Possession of a license as a medical professional. This requirement is not met evidenced by: Based records review, observation and interview , the licensee did not comply with the section cited above in 2 out of 4 staff having an expired medication training certificate.the state’s words, verbatim · CDSS document, Jul 14, 2025

Plan of correction: Licensee agreed to send the renewed medication certificate by POC due date

Type of visit: Prelicensing

Licensing Program Analysts (LPA) Janette Romero and Debbie Palacios made an announced visit to the facility to conduct a pre-licensing evaluation. LPAs met with Applicant, Robert Ramos and Administrator, Elizabeth Mahan whose administrator’s certificate expires on 2/28/2026. LPA Palacios toured the facility with Administrator Mahan. Indoor and outdoor passageways are free of obstruction. There are no bodies of water on the premises. LPA confirmed the fire department tested the facility's smoke alarms/carbon monoxide detectors during the fire inspection on 10/2/2024. The facility's fire extinguishers were last serviced on 8/19/2024. The facility has a central heating and air conditioning system installed with a central panel located in the hallway to control entire facility. LPAs toured a sample of resident bedrooms and found them to be adequately furnished with a bed, chair, lighting and closet storage. LPAs toured a sample of the resident bathrooms and observed them to have a working toilet, wash basin, with toilet paper, paper towels, and soap readily available. Bathrooms with showers have non-skid mats and grab bars in the showers. Facility has a barber room and activity room and an outside patio to have outdoor activities. LPAs tested the hot water temperatures is some of the bathrooms, which measured at 111.05, and 108.9-degrees Fahrenheit. LPAs toured the kitchen and observed the facility has a two-day supply of perishable foods and seven-day supply of non-perishable food items. Knives/sharp instruments will be secured in the kitchen. Medications are centrally stored in a locked cabinet in the medication room. Cleaning solutions and disinfectants are secured in a locked laundry room. The facility has a confidential storage area designated for staff and resident records. During today's visit, LPA did not observe any issues or concerns, and there are no corrections required. Applicant Ramos and Administrator Mahan are scheduled to attend the COMPIII tomorrow, 10/16/2024 at the Riverside Regional Office. Final approval of licensure will be granted by the CAB analyst. An exit interview was conducted, and a copy of this report was reviewed and provided to Applicant Ramos.the state’s words, verbatim · CDSS document, Oct 15, 2024

Type of visit: Office

Facility Type: RCFE Application Type: Initial Capacity: 36 Census (if any clients in care): 17 COMP II Participants: Elizabeth Mahan (Administrator) & Lucia Ramos (Board Member) Interview Method: Virtual interview via Microsoft Teams On October 08, 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, Oct 8, 2024