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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700301
Report Date: 08/08/2023
Date Signed: 08/08/2023 05:15:15 PM


Document Has Been Signed on 08/08/2023 05:15 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:FOZ, ROMERICOFACILITY TYPE:
740
ADDRESS:2100 BUTANO DRIVETELEPHONE:
(916) 481-9240
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:112CENSUS: 57DATE:
08/08/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Robert GTIME COMPLETED:
05:15 PM
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Licensing Program Analyst (LPA) Kevin Gould made an unannounced inspection to Country Club Manor (RCFE) on 8/8/23 at 9:00am to conduct a case management inspection to address areas of facility improvement.

LPA while conducting a walk through of the facility observed the bathroom in room 107 to be without required grab bars by the shower and toilet as required. LPA along with facility staff inspected another 10 rooms and did not observe any other bathrooms to be out of compliance. LPA did advise the facility staff to have the grab bars put in place in this bathroom and the work order is scheduled for Thursday 8/10/23.

LPA observed the food service and interviewed residents present. A number of residents interviewed did express disappointment with food service. LPA and facility staff discussed ways the facility can obtain more information regrading food preference and menu creation with resident input.

There are no deficiencies cited per California Code Regulation, TITLE 22. Advisory notes were provided to the facility including action items for the next resident council to discuss menu and food preferences for residents.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2023
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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