342700301-8-23-2021-27-AS-KHOS-C89JUJ-20211029072136

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700301
Report Date: 08/23/2021
Date Signed: 08/23/2021 11:03:37 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
08/13/2021 and conducted by Evaluator Christopher Hopkins-Clarke

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20210813112347

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: 53	DATE:	08/23/2021
		UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Maria Ciscoe		TIME COMPLETED:	11:05 AM

ALLEGATION(S):

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-Insufficient staff resulting in resident wandering out of facility and sustaining an injury

INVESTIGATION FINDINGS:

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On 8/23/2021 at 9:05am Licensing Program Analyst (LPA) Chris Hopkins arrived unannounced to deliver complaint investigation findings. LPA met with Administrator Maria Ciscoe and stated the purpose of the visit. This visit is to deliver the findings of the complaint investigation.

Regarding the allegation Insufficient staff resulting in resident wandering out of facility and sustaining an injury, the Department found the following; based on Interview and record review it was determined that Resident 1 (R1) fell outside in the gated back parking lot ( still on premises, where residents and staff park their cars), with no staff supervision. R1 is 101 years old. The cook who witnessed this fall happened to be outside at the time and notified care staff of the incident. Administrator stated that R1 had a previous incident where R1 was hiding behind the bush in the 2nd courtyard patio, and staff went looking for her and couldn't find her for some time (staff checked courtyard patio 3 times). R1 was eventually found.

Report Continued on LIC9099C...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Christopher Hopkins-Clarke	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2021

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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Control Number 27-AS-20210813112347

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: 08/23/2021

NARRATIVE

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LPA toured the facility and observed 2 courtyard patios that residents, have access to, some residents back door leads out to the patio, and LPA observed the gated back parking lot that residents have access to. Administrator stated that some residents partake in scheduled activity walks that happen in the gated back parking lot.

Based on interviews which were conducted and records reviewed, the preponderance of evidence standards has been met, therefore, the above allegation(s) is/are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited on the attached 9099D during this visit. Exit interview held, Appeal Rights discussed and given, Copy of report given.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Christopher Hopkins-Clarke	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2021

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
08/13/2021 and conducted by Evaluator Christopher Hopkins-Clarke

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20210813112347

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: 53	DATE:	08/23/2021
		UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Maria Ciscoe		TIME COMPLETED:	11:05 AM

ALLEGATION(S):

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-Staff are restricting residents from sugar food/drink items

INVESTIGATION FINDINGS:

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On 8/23/2021 at 9:05am Licensing Program Analyst (LPA) Chris Hopkins arrived unannounced to deliver complaint investigation findings. LPA met with Administrator Maria Ciscoe and stated the purpose of the visit. This visit is to deliver the findings of the complaint investigation.

Regarding the allegation, Staff are restricting residents from sugar food/drink items, the Department found the following: based on record reviews and Interviews it was determined that residents are provided dessert at least 4 times a week. Also if residents want to get more snacks or sodas then they have the opportunity to go on shopping trips with staff on Thursdays to get those items. Per the Administrator residents have the option for sugar free vs. non sugar free items if they want. The Department has investigated the allegation noted above and have found that this 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.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Christopher Hopkins-Clarke	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2021

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-20210813112347

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/23/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/26/2021 Section Cited CCR 87705(l)(6)	1 2 3 4 5 6 7	Care of Persons with Dementia 87705(l)(6) (l)The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: (6) Locked exterior doors or perimeter fences with locked gates shall not substitute for trained staff in sufficient numbers to meet the care and supervision needs of all residents. This was requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator has agreed to get a reassesment of the resident by the residents doctor, and will notify family. Administrator has also agreed to review section 87705 Care of Persons with Dementia and submit written notice of review. This is due by POC due date 8/26/2021.
	8 9 10 11 12 13 14	Based on interview and record review, Licensee did not enure resident was properly supervised. R1 sustained a fall with no supervision around. The cook who witnessed the fall just so happened to be outside at the time. This poses an immediate health, safety, and personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Christopher Hopkins-Clarke	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2021

LIC9099 (FAS) - (06/04)

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