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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005124
Report Date: 09/26/2023
Date Signed: 09/26/2023 12:14:32 PM


Document Has Been Signed on 09/26/2023 12:14 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 MANSIONFACILITY NUMBER:
347005124
ADMINISTRATOR:CENDANA-KEINATH, DIANAFACILITY TYPE:
740
ADDRESS:8920 CASELMAN ROADTELEPHONE:
(916) 689-5456
CITY:SACRAMENTOSTATE: CAZIP CODE:
95829
CAPACITY:6CENSUS: 4DATE:
09/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Diana Cendana-KeinathTIME COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual inspection on 09/26/2023 at 10:30 AM. LPA Martinez met with Diana Cendana-Keinath and stated the purpose of today’s visit. LPA Martinez inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards of the facility to ensure compliance with Title 22 regulations.

Administrator holds current certificate and expires on 04/30/2025. The facility is licensed for six non-ambulatory client, which two may be bedridden. Bedridden clients must reside in rooms with direct exiting only. There are currently 4 residents who reside at this facility.

LPA Martinez toured the facility with Diana Cendana-Keinath on 09/26/2023 at 12:00 PM. During today's annual inspection all clients were attending their day programs.

The facility is clean, sanitary, and furnished. Client bedrooms and common areas are furnished and sanitary. All toxins are locked, and Laundry room is sanitary and clean. The facility has a first aid kit, and medication are stored in a locked cabinet. LPA Martinez reviewed two medication files, and the files were complete and up to date. LPA Martinez reviewed staff and client files, which were complete. The facility smoke/carbon detectors were tested and in good repair. The facility fire extinguisher was inspected and is in good repair. The facility emergency gates are open and in good repair. The facility has an area for activities, and has shaded outdoor patio. The facility has a infection control plan and a natural disaster plan. The facility has an adequate food supply, and has utensils. All sharp utensils are locked. The facility bathrooms are sanitary. Based on this annual inspection, the facility is in compliance with California Code of Regulations, Title 22 and Health and Safety Code, there were no deficiencies cited at this time.

An exit interview was held, and a copy of this report was given at the end of the visit.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2023
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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