347005124-9-30-2026-27-AS-SLOZ-DYENCQ-20260930102109

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347005124
Report Date: 09/30/2026
Date Signed: 09/30/2026 10:21:17 AM

Document Has Been Signed on 09/30/2026 10:21 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 MANSION		FACILITY NUMBER:	347005124
ADMINISTRATOR/ DIRECTOR:	CENDANA-KEINATH, DIANA		FACILITY TYPE:	740
ADDRESS:	8920 CASELMAN ROAD		TELEPHONE:	(916) 689-5456
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95829
CAPACITY: 6		CENSUS: 4	DATE:	09/30/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Administrator Zolio "John" Cendana		TIME VISIT/ INSPECTION COMPLETED:	10:30 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 September 30, 2026, at 9:00 AM, Licensing Program Analyst (LPA) Sulma Lopez arrived unannounced at the facility to conduct an annual required inspection. LPA Lopez met with Administrator 1 (A1) John Cendana and explained the purpose of today's visit. The facility is licensed for 4 non-ambulatory and 2 ambulatory residents. There are currently 4 residents who reside at this facility. During the visit, all residents were away from the facility at their day programs. There were 2 staff present. At 9:10AM, LPA conducted record reviews of 4 staff and 4 resident files. Files were observed to contain the required components. Staff files contained updated annual training records. At 9:30AM, LPA conducted a medication administration review. Medications were stored in a locked cabinet. The facility uses a MAR sheet to record all dispensed medication to residents. At 9:40AM, LPA toured the facility with A1. The facility was clean, safe, and in good repair. The living room contained seating to accommodate the current census. A public telephone was available for resident use. The resident bedrooms were in good repair, and furnished with a dresser, lighting, bed, and night stand table. The furniture was observed to be in good repair. Bedroom windows and screens were both in good repair. The resident bedrooms contained clean linen and bedding. 2 out of 4 resident bedrooms contained direct exit doors. The exit doors were free of obstructions. Resident bedrooms contained working smoke detectors in each bedroom ceiling. Facility bathrooms were clean and sanitary. Non-slip mats and grab bars were available to ensure resident safety. Continued on LIC 809-C.

Arielle Pascua
Sulma Lopez
	DATE: 09/30/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2026

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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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 MANSION	FACILITY NUMBER: 347005124
	VISIT DATE: 09/30/2026

NARRATIVE

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The facility contained extra bedding and clean towels. The LPA inspected the staff office and staff room which were observed to be free of hazards.

The facility contained at least one week of non-perishable food supply and at least 2 days worth of perishable food items. The facility had a menu posted on the refrigerator. Residents' special diets and food sensitivities were also posted on the refrigerators. The kitchen contained cooking appliances which were observed to be in good working condition.

Sharps and toxins were stored in a locked area in the laundry room. The facility contained laundry appliances which were in good working condition.

LPA toured the exterior of the facility which was free of hazards. The walkways were free of obstructions. There was a shaded patio area with outdoor furniture available for resident use.

The facility temperature was 74 degrees. The hot water temperature was 108 degrees. The fire extinguishers were serviced annually on April 17, 2026.

LPA requested the following documents to be mailed/ faxed to the Regional Office within 15 days:
- LIC 500 Personnel Report, LIC 308 Designation of Facility Representative, LIC 610E Emergency and Disaster Plan, and a copy of the Liability Insurance Certificate.

As a result of this annual inspection, the facility is in compliance with Title 22 Regulations. An exit interview was conducted, and a copy of this report was provided to the facility.

NAME OF LICENSING PROGRAM MANAGER: Arielle Pascua
NAME OF LICENSING PROGRAM ANALYST: Sulma Lopez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/30/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2026

LIC809 (FAS) - (06/04)

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