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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700301
Report Date: 12/17/2021
Date Signed: 12/17/2021 12:03:07 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: 51DATE:
12/17/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Maricar VenegasTIME COMPLETED:
12:05 PM
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On December 17, 2021 at 10:40am Licensing Program Analyst (LPA) Chris Hopkins arrived at the facility unannounced to conduct a case management visit regarding an incident that happened on . LPA met with Administrator Maricar Venegas and explained the purpose of the visit.

This case management visit is regarding to an incident with Resident 1(R1) and Staff 1 (S1) that happened on 12/7/21 and 12/9/21. R1 claimed to have been touched inappropriately by S1. R1 told the Residential Care Coordinator (RCC) what happened, and the RCC conducted interviews with R1 and potential witnesses. There were no witnesses that saw directly what happened. RCC did speak to Staff 2 (S2) and S2 stated she/he went to R1's room to check on her but didn't see S1 in the room. R1 claimed Staff 3 (S3) was in the room and saw what happened, but S3 has been off of work since 12/1/21. Administrator has placed S1 on temporary leave to conduct her investigation. There is a scheduled mandatory staff meeting this Saturday 12/18/21 to conduct training. Administrator has stated that she will reassign S1 to a different job duty to prevent any other mishaps.

No deficiencies cited as a result of today's visit. An exit interview was conducted with Administrator Maricar Venegas and a copy of this report was left with Maricar Venegas.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021
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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