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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 03:34:45 PM


Document Has Been Signed on 06/21/2022 03:34 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:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Maricar VenegasTIME COMPLETED:
03:45 PM
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On June 21, 2022 at 2:20pm Licensing Program Analyst (LPA) Chris Hopkins arrived at Country Club Manor for the purpose of conducting an unannounced required 1 year annual inspection. LPA met with Administrator, Maricar Venegas and together conducted a tour of the facility.

LPA and Administrator toured 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, and outdoor areas. LPA observed the facility to be free of odor, clean and in good repair. LPA observed that rooms are equipped with the required furniture and sufficient lighting throughout the facility.

LPA measured the water temperature, temperature measured at 115 degrees F which meets the 105-120 degree Fahrenheit regulation. LPA observed sufficient seven-day non-perishable and two-day perishable food supplies. Fire extinguishers and smoke/carbon monoxide detectors are current and in compliance with fire safety. First aid kit was checked and is complete. LPA observed centrally stored medications, toxins, and sharp knives kept locked and inaccessible to clients. LPA reviewed Fingerprint clearance and associations to the facility as well as staff vaccination cards. The facility submitted a LIC 808 mitigation plan, which was approved. The facility has central entry point and has implemented screening and sign in procedures at the front door area. LPA observed the facility to have hand washing signs and COVID - 19 informational signs posted throughout the facility. The facility is able to designate and dedicate a Covid-19 room/bathroom if needed. Common touch surfaces are cleaned after each use.

LPA Requested the following documents for facility file: LIC 610E Emergency Disaster Plan and copy of Liability Insurance. Administrator has already submitted her current Administrator Certificate.

Per California Code of Regulations, Title 22 there were no deficiencies cited during today's inspection. An exit interview was conducted, and a copy of this report was left at the facility.
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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