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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700301
Report Date: 06/21/2022
Date Signed: 06/21/2022 02:18:59 PM


Document Has Been Signed on 06/21/2022 02:18 PM - It Cannot Be Edited

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:VENEGAS, MARICARFACILITY TYPE:
740
ADDRESS:2100 BUTANO DRIVETELEPHONE:
(916) 481-9240
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:112CENSUS: 58DATE:
06/21/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:24 PM
MET WITH:Maricar VenegasTIME COMPLETED:
02:20 PM
NARRATIVE
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On June 21, 2022 at 1:24pm 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 3-day eviction notice given to Resident 1(R1) without obtaining written approval from Community Care Licensing. Administrator gave R1 and responsible party a 3-day eviction on 6/8/22. Administrator learned the procedures on giving a 3-day eviction and rescinded the eviction notice the same day.

Based on today’s visit, deficiency is cited under Title 22, Division 6, Chapter 8. An exit interview was held with Administrator Maricar Venegas and a copy of this report was left. Appeal rights provided.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2022
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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Document Has Been Signed on 06/21/2022 02:18 PM - It Cannot Be Edited

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: 06/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/28/2022
Section Cited

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87224(b) Eviction Procedures
The licensee may, upon obtaining prior written approval from the licensing agency, evict the resident upon three (3) days written notice to quit. The licensing agency may grant approval for the eviction upon a finding of good cause...This requirement was not as evidenced by:
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Based on observation and record review, the Licensee did not ensure that the 3-day eviction notice was properly given to the resident. Licensing did not grant written approval prior to Licensee giving out 3-day eviction notice to Resident 1. This poses a potential health/safety risk to residents in care.
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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: Christopher Hopkins-ClarkeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2022
LIC809 (FAS) - (06/04)
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