342700301-7-1-2025-27-AS-CYAG-DJ6LTC-20250701090208

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700301
Report Date: 06/30/2025
Date Signed: 07/01/2025 09:02:16 AM

Document Has Been Signed on 07/01/2025 09:02 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:	DUNHAM, JOSEF		FACILITY TYPE:	740
ADDRESS:	2100 BUTANO DRIVE		TELEPHONE:	(916) 481-9240
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95825
CAPACITY: 112	TOTAL ENROLLED CHILDREN: 0	CENSUS: 89	DATE:	06/30/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:00 PM
MET WITH:	Kathryn Nevin		TIME VISIT/ INSPECTION COMPLETED:	03:00 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	Unannounced annual visit made out to this facility on 06/30/2025 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility Business Office Manager, Jennie Tello, who was briefly interviewed at this time. This LPA requested that she go ahead and contact the facility designated Administrator, Kathryn Nevin, to inform her that CCL was present at this time for an annual visit. It was learned that this facility currently has (3) residents under the care of hospice at this time. This facility does have an approved hospice waiver to be able to accept and retain up to (3) hospice residents at any given time. It was learned that there were 37 residents diagnosed with dementia at this time. It was learned that there were (4) residents receiving services through a home health agency at this time. It was learned that there was (1) resident deemed to be bedridden but was currently under the care of hospice at this time. Current census was 89 residents. Tour of the facility was conducted. Living area, dining area, and all other areas intended for resident use were toured. Furniture and furnishings were observed to be sufficient, in good repair, and able to meet the needs of the residents at this time. Kitchen area was toured. Cabinets and drawers were opened and the contents were reviewed at this time. Items for preparing, cooking, and serving meals unto the residents were observed to be sufficient and in compliance at this time. Cleaners and cleaning agents were observed to be locked and made inaccessible to the residents at this time. Fire extinguishers, located hanging on the walls throughout this facility, were observed to have been annually inspected on 09/26/2024 by the local fire extinguisher company, Sentinel Fire Equipment Co.,

Liza King	TELEPHONE: (650) 676-0442
Charlie Yang	TELEPHONE: (916) 709-6507
	DATE: 06/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2025

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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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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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: 06/30/2025

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and was in compliance at this time.
Medication room was observed to be locked and made inaccessible to the residents at this time. An interview was conducted with the facility medication technician and a brief review of the narcotics count log was conducted at this time.
First aid kits were observed to be present and contained all of the required components at this time.
Food supply, and food storage units, were observed to be sufficient and able to meet the needs of the residents at this time. This facility was observed to have, on hand at all times, a sufficient supply of 2-day perishable and 7-day nonperishable food quantities at this time.
A tour of the facility bedrooms was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
A tour of the facility restrooms was conducted. Grab bars, non skid mats, and toiletries were observed to be sufficient and able to meet the needs of the residents at this time.
Hot water temperatures were taken to make sure that they were within the allowed range of 105-120 degrees at this time.
A review of the laundry room was conducted. Bleach, detergent, and all other laundry supplies were observed to be locked and made inaccessible to the residents at this time.
Exterior grounds of this facility were toured. Facility perimeter fence, side gates, and all other exits were reviewed at this time.
Administrator certificate for the facility designated Administrator, Kathryn Nevin, was observed to be present with certificate number 6077502740 and set to expire on 05/26/2027.

A review of (5) facility personnel files was conducted and noted on the following LIC 859.
A review of (5) facility resident files was conducted and noted on the following LIC 858.

The following forms and documents were requested to be updated and submitted into CCL:
LIC 308
LIC 400
LIC 500
LIC 610

There were no deficiencies observed or cited during today's annual visit.
Exit Interview

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 06/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2025

LIC809 (FAS) - (06/04)

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