342700301-10-22-2021-27-AS-KHOS-C89J5L-20211029064454

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700301
Report Date: 10/22/2021
Date Signed: 10/22/2021 05:02:25 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
10/07/2021 and conducted by Evaluator Anthony Tuck

COMPLAINT CONTROL NUMBER: 27-AS-20211007105407

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: 57	DATE:	10/22/2021
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Administrator Maria Ciscoe		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff did not maintain a comfortable temperature in the facility

Staff mismanaged resident's medication

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Anthony Tuck arrived at the facility location on 10/22/2021 unannounced. LPA was met by Administrator Maria Ciscoe. LPA explained the purpose of the visit obtain additional resident and staff interviews in regards to the complaint allegations listed above.

LPA conducted interviews with 5 additional residents and 1 staff during today's visit on 10/22/2021. LPA interviewed R4, R5, R6, R7, and R8. LPA conducted 1 interview with S3 during today's visit. LPA conducted a total of 8 resident interviews and 3 staff interviews.
LPA reviewed a copy of work order invoice for HVAC system. LPA reviewed pertinent resident documents for R1 and R2. LPA learned that 7 out of 8 residents interviewed indicated the room temperature is fine. LPA learned from 3 staff interviews that the facility maintains a comfortable room temperature throughout the day. LPA learned that 7 out of 8 residents have no issues with receiving their medications.
Continued on LIC 9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Anthony Tuck	TELEPHONE: (916) 708-6203
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2021

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-20211007105407

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: 10/22/2021

NARRATIVE

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Based upon interviews conducted with residents, staff and review of pertinent documents received, there is not substantial evidence to support or disprove that the alleged violations occurred. Due to the preponderance of evidence standard not being met by the department standard. There is no physical evidence to support the validity of the allegations as well as witness statements; LPA has deemed the complaint findings as UNSUBSTANTIATED. Although the allegations may have happened and/or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted with Administrator Maria Ciscoe. A copy of this report was left with Administrator upon exit.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Anthony Tuck	TELEPHONE: (916) 708-6203
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2021

LIC9099 (FAS) - (06/04)

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