342700301-7-30-2021-27-AS-MSEY-C5MQ8M-20210806115657

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700301
Report Date: 07/30/2021
Date Signed: 07/30/2021 01:01:32 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
01/06/2021 and conducted by Evaluator Melissa Lusby

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20210106121120

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: 48	DATE:	07/30/2021
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Maria Ciscoe		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Facility staff yell at residents

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 residents. Based on LPA's interviews the preponderance of evidence standards was not met, therefore, the above allegation is 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.

Unfounded

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Melissa Lusby	TELEPHONE: (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)

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