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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700301
Report Date: 07/30/2021
Date Signed: 07/30/2021 12:03:59 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/19/2021 and conducted by Evaluator Melissa Lusby
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20210119100407
FACILITY NAME:COUNTRY CLUB MANORFACILITY NUMBER:
342700301
ADMINISTRATOR:CISCOE, MARIAFACILITY TYPE:
740
ADDRESS:2100 BUTANO DRIVETELEPHONE:
(916) 481-9240
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:112CENSUS: 48DATE:
07/30/2021
UNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Maria CiscoeTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Facility is not administering medications as prescribed
INVESTIGATION FINDINGS:
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LPA Lusby arrived on Friday July 30, 2021 to conclude the complaint investigation regarding the above allegations. Prior to the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask.
Throughout the course of the investigation, LPA interviewed staff and reviewed R1's physicians report, medication administration record, resident care notes, incident report and other relevant documents. LPA observed over 25 unsigned medications between December 2020 and January 2021. There were no records to explain why medications were missed. As a result of this investigation, the Department finds the allegation to be Substantiated.
(continued on 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Melissa LusbyTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/19/2021 and conducted by Evaluator Melissa Lusby
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20210119100407

FACILITY NAME:COUNTRY CLUB MANORFACILITY NUMBER:
342700301
ADMINISTRATOR:CISCOE, MARIAFACILITY TYPE:
740
ADDRESS:2100 BUTANO DRIVETELEPHONE:
(916) 481-9240
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:112CENSUS: 48DATE:
07/30/2021
UNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Maria CiscoeTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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9
Facility interfering with medical care
Resident is not receiving showers on a regular basis
INVESTIGATION FINDINGS:
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LPA Lusby arrived on Friday July 30, 2021 to conclude the complaint investigation regarding the above allegations. Prior to the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask.

Throughout the course of the investigation, LPA interviewed staff and reviewed relevant documents. LPA was able to determine that R1 was showered routinely. Additionally, R1 scheduled his own transportation for medical appointments. The facility assisted when needed. Based on LPA's interviews, the preponderance of evidence standards was not
(continued on 9099-C)
Unfounded
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Melissa LusbyTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20210119100407
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: COUNTRY CLUB MANOR
FACILITY NUMBER: 342700301
VISIT DATE: 07/30/2021
NARRATIVE
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met, therefore, the above allegations are found to be UNFOUNDED. An unfounded allegation means that the allegation was false, could not have happened and/or is without a reasonable basis. LPA Lusby conducted an exit interview. A copy of this report was left at the facility.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Melissa LusbyTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20210119100407
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: COUNTRY CLUB MANOR
FACILITY NUMBER: 342700301
VISIT DATE: 07/30/2021
NARRATIVE
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 A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency is cited on 9099-D, per Title 22 Regulations, Division 6. Exit interview conducted. Appeal rights and a copy of this report was given to Administrator Maria.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Melissa LusbyTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 27-AS-20210119100407
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: COUNTRY CLUB MANOR
FACILITY NUMBER: 342700301
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/30/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/02/2021
Section Cited
CCR
87465(a)(5)
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Incidental Medical and Dental Care
(a) A plan for incidental medical and dental care shall be developed by each facility.. . (5) The licensee shall assist residents with self-administered medications as needed.
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Administrator to submit plan related to quality assurance and MAR auditing. Administrator to submit documents showing all med techs have been retrained regarding proper MAR documentation.
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This requirement was not met as evidenced by unsigned medication administration dates for prescribed routine medications in December 2020 and January 2021 for R1. This poses an immediate threat to the health and safety of residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Melissa LusbyTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5