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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700301
Report Date: 05/02/2023
Date Signed: 05/04/2023 12:19:11 PM


Document Has Been Signed on 05/04/2023 12:19 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: 103DATE:
05/02/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:11 PM
MET WITH:Mary Lungren and Robert Godfrey, Regional Director of OperationsTIME COMPLETED:
03:57 PM
NARRATIVE
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LPA Johnson arrived and met with the Regional Director, who assisted LPA with the visit. The purpose of this visit was to follow up on the citations given and amend the deficiency from an "A" to a "B" to reflect the non-immediate safety risk to R1.

The appeal to the Department questioned that the failure to follow a proper medication order for R1 did not pose an immediate health and safety risk to R1 and a Type "A" deficiency was not warranted. The facilities presented that R1 never had any adverse medical outcome due to the error and therefore the "A" citation was not warranted and should be a "B" citation instead.

LPA reviewed records and medications charting for R1. To confirm that the medication are present and being given according to the doctors orders.

LPA Johnson and Mary were walking to the medication room to get the medication administration record for R1, LPA and Mary observed and confirmed that the housekeeping cart was absent of the housekeeper or unmanned in the main hallway with unlocked toxins accessible to the residents (Zeps wall cleaner and other unmarked cleaning items.) Mary was able to locate the housekeeper and informed her that the cart should be locked at all times when she is not present. The housekeeper locked the cart.

As a result of this visit deficiencies were observed and cited on the attached 809D page. LPA provided the facility with a report to amend the citation and appeal rights for the citation today.

Exit interview conducted
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 05/04/2023 12:19 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: 05/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/08/2023
Section Cited

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87309 Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients
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Staff immediately locked the cart. Facility will ensure that toxins are kept locked and inaccessible to all clients in care. The immediate action of locking the cart met the requirement for the "A" citation correction. however an inservice will be completed by 5/8/23 to address the danger of unlocked cleaning solutions.
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This requirements was not met as evidenced by observation by Staff and LPA also by checking the unlocked cart. This poses an immediate health and safety risk to residents in care.
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Facility shall submit a plan on how the facility will keep toxins locked by POC date

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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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2