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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700301
Report Date: 04/06/2023
Date Signed: 04/06/2023 03:34:29 PM


Document Has Been Signed on 04/06/2023 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
SACRAMENTO AC/SC, 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:
04/06/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Robert Godfrey, Regional Director of OperationsTIME COMPLETED:
04:00 PM
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LPA's Brandon Panariello and Kevin Gould conducted an unannounced case management inspection on 4/6/23 at 12:55pm. LPAs met with the Regional Director of Operations (RDO) of Cimino Care to discuss and obtain additional information regarding the reported incident.

LPAs conducted interviews with two staff members. LPAs were informed the facility suspected and has obtained evidence the former administrator was falsifying employee time sheets and not meeting requirements to ensure three facility staff members obtained. LPAs provided RDO with LIC 855 Declaration forms to have filled out by any staff with knowledge of the alleged violations and returned to the department.

LPAs have requested the facility staff files for 6 identified staff members. Facility was unable to provide at the time of inspection due to being removed for an internal investigation by the facility.

For appointing a new administrator for the facility, LPAs have requested the following documents to be filled out by the appropriate corporate individuals. LIC 200 - Facility Application Form, LIC 308 - Designation of Facility responsibility, LIC 500 - Personnel Record, LIC 501 - Personnel Report, College Transcripts and board resolution designating new administrator and current Administrator Certificate.

Per California Code of Regulations, Title 22, there were no deficiencies issued during today's inspection. An Exit interview was conducted with the regional director and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) -26-4723
LICENSING EVALUATOR NAME: Brandon PanarielloTELEPHONE: 323-558-2130
LICENSING EVALUATOR SIGNATURE:
DATE: 04/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2023
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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