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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700301
Report Date: 07/05/2024
Date Signed: 07/05/2024 11:06:02 AM


Document Has Been Signed on 07/05/2024 11:06 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 MANORFACILITY NUMBER:
342700301
ADMINISTRATOR:DUNHAM, JOSEFFACILITY TYPE:
740
ADDRESS:2100 BUTANO DRIVETELEPHONE:
(916) 481-9240
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:112CENSUS: 63DATE:
07/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH: Josef DunhamTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct an annual required inspection. LPA Valerio was met by Administrator Josef Dunham, and explained the purpose of the visit.

LPA Valerio and Administrator Josef Dunham toured the physical plant to ensure compliance with Title 22 regulations. Resident bedrooms were observed to be fully furnished and free from odors. Resident bathrooms were observed to have hygiene supplies, grab bars, skid mats, hand soap, and toilet paper. Resident common shower rooms were occupied during the time of visit. Common areas, including the activities area, dinning room, and front lobby, were organized, clean, and fully furnished. Residents were observed eating breakfast, inside their rooms, walking in the hallway, and being assisted with ADLs. Staff were observed. Medications, cleaning supplies, and sharp objects were locked and inaccessible to residents in care. The facility temperature was at a comfortable temperature and within regulatory range. No health or safety concerns observed during today's visit.

LPA Valerio reviewed six (6) resident files and five (5) staff files. Resident files were observed to be current with required documents. Staff files were complete and observed to have required annual training. Administrator J. Dunham was observed to have an active administrator certificate.

LPA Valerio requested the following annual documentation be sent via e-mail to christina.valerio@dss.ca.gov for the Regional Office facility file: LIC 500, LIC 308, LIC 610D, and copy of Liability Insurance

Per California Code of Regulations (CCR) - Title 22, no deficiencies are being cited today. An exit interview was held, and a copy of the report was provided.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 07/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2024
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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