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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700301
Report Date: 08/12/2021
Date Signed: 08/12/2021 09:56:03 AM



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
04/26/2021 and conducted by Evaluator Tung Truong
COMPLAINT CONTROL NUMBER: 27-AS-20210426083845
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: 55DATE:
08/12/2021
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator, Maria CiscoeTIME COMPLETED:
10:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility heater is in disrepair
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 8/12/2021, Licensing Program Analyst (LPA) Tung Truong conducted an unannounced visit to this facility to deliver the complaint findings. LPA identified himself and discussed the purpose of the visit and the elements of the allegation(s) with Administrator Maria Ciscoe.

Throughout the course of the investigation, LPA conducted interviews and reviewed records. Based on the investigation, the facility heater was observed to be in working order. The facility temperature was observed at 73 degrees Fahrenheit. Residents (R2) and (R6) stated during the Winter the facility is hot when the heater is on. Residents (R3) and (R4) stated they have no complaints about room temperature.

Report Continued on 9099-C
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2021
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 4
Control Number 27-AS-20210426083845
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: COUNTRY CLUB MANOR
FACILITY NUMBER: 342700301
VISIT DATE: 08/12/2021
NARRATIVE
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This Department has investigated the allegation noted above and have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or was without a reasonable basis. This Department has therefore dismissed the complaint.

Exit interview was conducted with Administrator Maria Ciscoe and a copy of the report was provided.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
04/26/2021 and conducted by Evaluator Tung Truong
COMPLAINT CONTROL NUMBER: 27-AS-20210426083845

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: 55DATE:
08/12/2021
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator, Maria CiscoeTIME COMPLETED:
10:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Food is being served cold.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 8/12/2021, Licensing Program Analyst (LPA) Tung Truong conducted an unannounced visit to this facility to deliver the complaint findings. LPA identified himself and discussed the purpose of the visit and the elements of the allegation(s) with Administrator Maria Ciscoe.

Throughout the course of the investigation, LPA conducted interviews and reviewed records. Based on the investigation, there were insufficient evidences to substantiate that food was being served cold. Residents (R2, R3, and R4) stated food was warm. Residents (R5 and R6) stated food was sometime cold, but mostly warm. Resident (R1) said food is delicious and not being served cold.

Report Continued on 9099-C

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20210426083845
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: COUNTRY CLUB MANOR
FACILITY NUMBER: 342700301
VISIT DATE: 08/12/2021
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
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28
29
30
31
32
Based on information obtained, the department finds the allegation to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview was conducted with Administrator and a copy of the report was provided.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4