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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700301
Report Date: 04/14/2023
Date Signed: 04/14/2023 02:11:31 PM


Document Has Been Signed on 04/14/2023 02:11 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:
04/14/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Mary Lindgren TIME COMPLETED:
02:20 PM
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On April 14, 2023 At 2:00 PM, Licensing Program Analysts (LPA) Avelina Martinez and LPA Pang Lee arrived unannounced to deliver an Order of Exclusion for a staff member. LPAs Martinez and Lee met with Mary Lindgren and explained the purpose of today's visit.

LPAs Martinez and Lee were informed by Mary Lindgren, staff member named in the Order of Exclusion, Maricar Venegas is no longer employed at this facility.

LPAs Martinez and Lee provided Mary Lindgren with a copy of the Order and explained that Maricar Venegas is not allowed in the facility effective immediately.

Exit interview was held, and a copy of this report and Immediate Exclusion letter were provided to the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2023
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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