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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700301
Report Date: 09/09/2021
Date Signed: 09/09/2021 02:59:56 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:
09/09/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:01 PM
MET WITH:Maria CiscoeTIME COMPLETED:
03:02 PM
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LPA Johnson arrived unannounced to clear the POC's from visit dated 06/25/2021.The following deficiencies, initially cited during a visit on 06/25/2021, have been cleared:

Section Cited: 87303(e)(2)Date Due: 06/28/2021
Plan of Correction:
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. 		Corrections:
Cleared By Visit		Clearance Date:
09/09/2021
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021
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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