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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005124
Report Date: 10/30/2024
Date Signed: 10/30/2024 11:53:42 AM

Document Has Been Signed on 10/30/2024 11:53 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 MANSIONFACILITY NUMBER:
347005124
ADMINISTRATOR/
DIRECTOR:		CENDANA-KEINATH, DIANAFACILITY TYPE:
740
ADDRESS:8920 CASELMAN ROADTELEPHONE:
(916) 689-5456
CITY:SACRAMENTOSTATE: CAZIP CODE:
95829
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 4DATE:
10/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:35 AM
MET WITH:Diana Cendana-KeinathTIME VISIT/
INSPECTION COMPLETED:
12:10 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct an annual required inspection. LPA Valerio was met by facility staff, and explained the purpose of the visit. LPA was later met by Administrator Diana Cendana-Keinath.

LPA Valerio observed one staff on shift and zero residents present in the facility. According to facility staff, all residents have gone to their Day Program for the day. LPA Valerio and Administrator toured the physical plant to ensure compliance with Title 22 regulations. LPA Valerio inspected the facility kitchen. The kitchen was observed to be clean and organized. The facility was observed to have a minimum supply of two days of perishable food items and a seven day supply of non-perishable food items. All sharps, cleaning supplies, and toxins were observed to be locked and inaccessible to residents in care. Medications were observed to locked at the time of the visit. The living room area was fully furnished with areas for exercise and lounging. Resident bedrooms were observed to be fully furnished and free from odors. Bathrooms were observed to be clean and fully stocked with hygiene products, a skid mat, and a shower chair. The exterior areas was observed to have areas for outdoor seating, outdoor activities, and gardening activities. No emergency exits were observed to be obstructed.

LPA Valerio reviewed two (2) resident files and two (2) staff files. LPA observed resident files to be complete with annual documentation. Staff files were up to date with required annual training.

LPA requested the following annual documentation be sent to (916) 263 - 4747: LIC 500, LIC 308, LIC 610, Copy of Liability Insurance

Per California Code of Regulations (CCR) Title 22 - Division 6, Chapter 8, no deficiencies are being cited today. An exit interview was held, and a copy of the report was provided.
Stephen RichardsonTELEPHONE: (916) 263-4746
Christina ValerioTELEPHONE: 916-823-6323
DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2024
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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