342700301-8-4-2026-27-AS-SLOZ-DWMPQQ-20260804113131

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700301
Report Date: 08/04/2026
Date Signed: 08/04/2026 11:31:39 AM

Document Has Been Signed on 08/04/2026 11:31 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	COUNTRY CLUB MANOR		FACILITY NUMBER:	342700301
ADMINISTRATOR/ DIRECTOR:	KATHRYN NEVIN		FACILITY TYPE:	740
ADDRESS:	2100 BUTANO DRIVE		TELEPHONE:	(916) 481-9240
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95825
CAPACITY: 112		CENSUS: 63	DATE:	08/04/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Kathryn Nevin		TIME VISIT/ INSPECTION COMPLETED:	11:30 AM

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	On August 4, 2026, at 9:00AM, Licensing Program Analyst (LPA) Sulma Lopez and Licensing Program Manager (LPM) Arielle Pascua arrived unannounced at the facility to conduct an annual inspection. LPA met with Facility Administrator Kathryn Nevin and explained the purpose of the visit. The facility has a capacity for (112) residents over 60 years old and is approved for (30) hospice residents. The current census is 59 total residents. There are currently (4) residents on hospice, and (5) dementia residents. During the inspection, LPA reviewed (6) staff files, and (6) resident files. The files are maintained current. The administrator holds a current Administrators Certificate #6077502740 with an expiration date of 05/26/2027. The facility holds a current Infection Control Plan. At 10:30AM, LPA began a tour of the facility with the Administrator. LPA observed the facility sunroom and hallways which were free of debris and tripping hazards. The hallways are equipped with various carbon monoxide and smoke detectors in good working condition. LPA observed the fire extinguishers have been annually inspected on 09/26/2025. LPA observed the living room area which contained ample seating for resident use. Residents were participating in chair exercise with staff instruction. LPA also inspected resident bedrooms which contained furnishings in good repair. The bedrooms were clear of debris and hazards. At 10:45AM, LPA observed the laundry room which contained extra clean linens. LPA observed the medication room and reviewed the first aid kit which contained all the required components. Continued...

Arielle Pascua
Sulma Lopez
	DATE: 08/04/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2026

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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: COUNTRY CLUB MANOR	FACILITY NUMBER: 342700301
	VISIT DATE: 08/04/2026

NARRATIVE

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LPA proceeded to review the dining hall and kitchen area. LPA observed the facility contained at least a 7-day supply of non-perishable foods in the pantry, and 2- day perishable food supply in the walk-in refrigerator. Cleaning supplies were locked, and the kitchen was in sanitary condition. LPA observed the weekly menu was posted on various locations throughout the kitchen and dining hall. There was an updated Activities Calendar for the month of August.

At 10:50AM, LPA toured the courtyard which was free of tripping hazards. LPA observed a covered patio with a seating area available for resident use. No bodies of water were present.

The following documents were requested:
LIC 500
LIC 308
LIC 610E

No deficiencies were cited during today's visit. An exit interview was conducted and a copy of this report was provided to the administrator.

NAME OF LICENSING PROGRAM MANAGER: Arielle Pascua
NAME OF LICENSING PROGRAM ANALYST: Sulma Lopez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/04/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2026

LIC809 (FAS) - (06/04)

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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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