342700301-6-30-2023-27-AS-TTRG-CTAVP6-20230630163612

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700301
Report Date: 06/30/2023
Date Signed: 06/30/2023 04:36:20 PM

Document Has Been Signed on 06/30/2023 04:36 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 MANOR		FACILITY NUMBER:	342700301
ADMINISTRATOR:	STONSBY, ELIZA		FACILITY TYPE:	740
ADDRESS:	2100 BUTANO DRIVE		TELEPHONE:	(916) 481-9240
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95825
CAPACITY:	112	CENSUS: 57	DATE:	06/30/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Mark Cimino, Licensee		TIME COMPLETED:	04:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Tung Truong conducted an unannounced 1 Year Annual Inspection visit at this facility on 6/30/23. LPA met with Licensee Mark Cimino and explained the purpose of the visit. Licensee will assist LPA with today’s inspection. The licensee is designating Romerico Foz as the new facility administrator. Romerico Foz holds current certificate # 6013248740 and expires on 6/25/2024. LPA toured and inspected the physical plant inside and outside to ensure there were no health and safety concerns. LPA observed the lounge area, lobby, and common areas. In addition, the kitchen areas, dining area, and activity room was toured. Medication room was toured. LPA observed the centrally stored medication areas to be locked and made inaccessible to the residents at this time. Kitchen was toured for adequate food supplies and storage. LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. LPA observed required furniture and lighting throughout the facility. The hot water temperature was measured and is within the required range of 105-120F. The temperature inside the facility measured at 72F which was within the required range of 68-85*F. LPA observed the fire extinguisher(s) and first aid kits were up to date. Smoke and carbon monoxide detector(s) in the facility were in good repair. LPA and Licensee tested the emergency pull cord system and it was in good repair. Continued on 809-C

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 06/30/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2023

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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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
	VISIT DATE: 06/30/2023

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LPA requested resident and staff files for review. LPA reviewed (8) resident files and (8) staff files, including criminal record clearances. LPA reviewed staff associations to the facility. A full Care Tool Inspection was completed at facility. Proof of current liability insurance was observed.

Licensee was informed to send updated copies of the following documents to CCL within 15 days: LIC 500 Personnel Report, LIC 610 Emergency Disaster Plan.

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was conducted and a copy of this report was provided.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 06/30/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2023

LIC809 (FAS) - (06/04)

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