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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700301
Report Date: 06/25/2021
Date Signed: 06/25/2021 04:01:26 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: 48DATE:
06/25/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Maria CiscoeTIME COMPLETED:
04:30 PM
NARRATIVE
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On 06/25/21 at 2:15pm Licensing Program Analyst (LPA) Kevin Gould arrived at Country Club Manor for the purpose of conducting a required 1 year annual inspection. LPA met with Administrator, Maria Ciscoe and together conducted a tour of the facility.

LPA and Administrator evaluated the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and outdoor areas. LPA observed the facility to be free of odor, clean and in good repair. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility.

LPA measured the water temperature, temperature measured at 93.5 degrees F in room #6 and 130 degrees F which does not meet the 105-120 degree Fahrenheit regulation. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA notes the facility had the required carbon monoxide detectors. First aid kit was checked and is complete. LPA observed centrally stored medications secure from residents.

LPA Requested the following documents for facility file: LIC 308 Designation of Facility Responsibility, LIC 500 personnel report, LIC 610E Emergency Disaster Plan, Current Administrator Certificate and Client Roster

The following deficiencies were observed and cited Per California Code of Regulations, Title 22 during today's inspection. An exit interview was conducted, a copy of this report and appeal rights was left at the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 MANOR
FACILITY NUMBER: 342700301
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/25/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs testing of water temperatures in rooms 6 and 152, LPA recorded temperatures of 93.5 degrees and 130 degrees F respectively the licensee did not comply with the section cited above in as the water temperature was not inside the approved approved varience of 105 to 120 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/28/2021
Plan of Correction
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LPA observed the facility Administrator turn town the water temperature from 130 to below 120 degrees. Facility will conduct water temperature logs for two weeks to ensure the hot water temperature is within regulations and the hot water is porperly circulated throughouth the facility.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 06/25/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/25/2021
LIC809 (FAS) - (06/04)
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