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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700301
Report Date: 12/15/2021
Date Signed: 12/15/2021 11:24:11 AM

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:
12/15/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Maricar VenegasTIME COMPLETED:
11:30 AM
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On December 15, 2021 at 9:00am Licensing Program Analyst (LPA) Chris Hopkins arrived at the facility unannounced to conduct a case management visit. LPA met with Administrator Maricar Venegas and explained the purpose of the visit.

This case management visit is to follow up on a delinquent notice the Department received on 12/14/21 charged to Solar Senior Living 2 LLC in the amount of $21,948.24. LPA spoke to Administrator, Solar Senior Living 2 LLC Management member Johnathan Harris, and Controller (handles finances) of Cimino Care Bryan Hart. Bryan Hart has stated that the company has worked with Employment Development Department (EDD) to resolve any outstanding payment issues. Solar Senior Living 2 LLC and Cimino Care has provided LPA with Lien Release documents, clearing the $21,948.24.

LPA also requested copies of the following documents:
  • LIC 308
  • LIC 200 designating new administrator
  • LIC 500
  • LIC 501
  • Administrator certificate

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: 12/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2021
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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