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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700301
Report Date: 07/05/2023
Date Signed: 07/05/2023 04:23:22 PM


Document Has Been Signed on 07/05/2023 04:23 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:STONSBY, ELIZAFACILITY TYPE:
740
ADDRESS:2100 BUTANO DRIVETELEPHONE:
(916) 481-9240
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:112CENSUS: 57DATE:
07/05/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Mark Cimino, LicenseeTIME COMPLETED:
04:40 PM
NARRATIVE
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On 7/5/23, Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct a case management visit to follow up on an incident report. LPA met with Licensee Mark Cimino and explained the purpose of today’s visit.

The purpose of this case management visit is to follow up on concerns learned from an incident report the facility submitted to the Department on 6/21/23. The facility reported that on 6/20/23, resident (R1) ran into the kitchen, grabbed the knives and started throwing them at the kitchen staff. Based on interviews and records review, it was determined that the facility did not ensure that knives were kept locked and inaccessible to residents. LPA observed the knives were not kept locked and is accessible to residents.

Deficiencies were observed and cited on the LIC 809-D pursuant to the California Code of Regulations, Title 22, and California Health and Safety Code.

An exit interview was conducted, a copy of this report, LIC 809-D and appeal rights were left at the facility. Failure to correct any deficiencies by plan of correction due date(s) may result in civil penalties.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:
DATE: 07/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2023
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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Document Has Been Signed on 07/05/2023 04:23 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: 07/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/06/2023
Section Cited
CCR
87705(f)(1)

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87705 Care of Persons with Dementia. (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
This requirement is not met as evidence by:
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Licensee agrees to submit a plan of correction to LPA by 7/6/2023 on how the facility will be in compliance with regulation 87705(f)(1) at all times.
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Based on interviews and records review, the licensee did not comply with the regulation cited above. LPA observed knives were not stored inaccessible to residents which poses an immediate health and safety risk to residents in care.
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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: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:
DATE: 07/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2023
LIC809 (FAS) - (06/04)
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