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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700301
Report Date: 06/12/2020
Date Signed: 06/12/2020 04:39:18 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:COUNTRY CLUB MANORFACILITY NUMBER:
342700301
ADMINISTRATOR:CISCOE, MARIAFACILITY TYPE:
740
ADDRESS:2100 BUTANO DRIVETELEPHONE:
(916) 481-9240
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:112CENSUS: 57DATE:
06/12/2020
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Country Club Manor RepresentativesTIME COMPLETED:
11:45 AM
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An informal conference was held today in the Sacramento Regional office via ZOOM due to COVID-19 and pre-cautionary measures.The purpose of today's meeting was to address concerns the Department has identified regarding medication management, staffing, staff training and the overall management of the facility.
The following Licensing staff were present:
Alycia Berryman, Regional Manager; Laura Munoz, Licensing Program Manager; Troy Ordonez, Licensing Program Manager; Danyle Wolter, Licensing Program Analyst; Jasmine McCrory, Licensing Program Analyst

The following representatives were present:
Glen Silverman, CEO of Solar Senior Living 2; Mark Cimino, CEO of Cimino Care; Jonathan Harris, Management Member; Adina Nitu, Cimino Care Regional Director ; Maria Ciscoe, Country Club Manor Administrator; Rachel Blucher, Attorney for Licensee

The facility has identified the following remedies to achieve continued and substantial compliance:
1. Medication audits will be conducted 2x a year by an approved outside vendor. First medication audit will be conducted by 07/17/2020.
2. Facility compliance audit will be conducted 06/30/2020 -07/01/2020
3. Medication training with staff who dispense medications will be completed within 30 days of today's date
4. a receptionist will be present in the facility 24 hours a day
5. The facility currently has scheduled 2 full-time med techs for both am/pm shifts and 1 during NOC shift
6. Facility will cross-training caregivers on medication administration
7. The licensees have agreed to be referred to the Departments Technical Support Program (TSP)

At this time, no deficiencies are cited. An exit interview was conducted with all mentioned representatives via ZOOM and a copy of this report will be provided to the facility via email. A copy must be signed and returned to Community Care Licensing (CCL) and the one copy is to be retained by the facility.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jasmine McCroryTELEPHONE: (916) 214-5020
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2020
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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