342700301-12-11-2020-27-AS-JMCY-BW7V5F-20201211150753

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700301
Report Date: 11/05/2020
Date Signed: 12/11/2020 03:07:53 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/02/2020 and conducted by Evaluator Jasmine McCrory

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20201102163552

FACILITY NAME:	COUNTRY CLUB MANOR		FACILITY NUMBER:	342700301
ADMINISTRATOR:	CISCOE, MARIA		FACILITY TYPE:	740
ADDRESS:	2100 BUTANO DRIVE		TELEPHONE:	(916) 481-9240
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95825
CAPACITY:	112	CENSUS: 55	DATE:	11/05/2020
		UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	Maria Ciscoe, Administrator		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Facility is not allowing residents to access common rooms, without just cause.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) McCrory contacted Facility Administrator (Admin) Maria Ciscoe to open and deliver complaint findings over the phone due to COVID-19 and precautionary measures. LPA informed Admin of the purpose of the call. Community Care Licensing (CCL) received the following complaint: Facility is not allowing residents to access common rooms, without just cause.

CCL conducted interviews, reviewed LIC 624 Unusual Incident/ Injury Report dated 11/03/2020 and analyzed PIN-20-38-ASC. PIN 20-38-ASC advises licensees of facilities that, “if you or other residents contract or were exposed to COVID-19, you should not participate in communal dining, group activities, access shared facility amenities or equipment, or obtain facility salon services.” Due to a current positive case at this facility the actions of the Administrator have just cause.

Therefore, the allegation is UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jasmine McCrory	TELEPHONE: (916) 214-5020
LICENSING EVALUATOR SIGNATURE:	DATE: 11/05/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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