342700301-11-10-2021-27-AS-KHOS-C99R5L-20211130114319

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700301
Report Date: 11/10/2021
Date Signed: 11/10/2021 04:50:21 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
11/05/2021 and conducted by Evaluator Christopher Hopkins-Clarke

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20211105120333

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:	11/10/2021
		UNANNOUNCED	TIME BEGAN:	03:22 PM
MET WITH:	Maria Ciscoe		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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-Resident has no call button

INVESTIGATION FINDINGS:

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On November 10, 2021 at 3:22pm Licensing Program Analyst (LPA) Chris Hopkins arrived unannounced to conduct a complaint investigation. LPA met with Administrator Maria Ciscoe and stated the purpose of the visit.

Regarding the allegation of Resident has no call button, the Department found the following: based on observation and interview, Resident 1 (R1) call button was not working at all. LPA observed this to be the case as well. LPA told the Administrator that R1's call button was not working. Administrator then called maintenance to fix the issue.

Based on observation and interview, 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.

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: 11/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2021

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 3

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
11/05/2021 and conducted by Evaluator Christopher Hopkins-Clarke

COMPLAINT CONTROL NUMBER: 27-AS-20211105120333

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:	11/10/2021
		UNANNOUNCED	TIME BEGAN:	03:22 PM
MET WITH:	Maria Ciscoe		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

1
2
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5
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7
8
9

-Staff did not maintain a comfortable temperature in the facility

INVESTIGATION FINDINGS:

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On November 10, 2021 at 3:22pm Licensing Program Analyst (LPA) Chris Hopkins arrived unannounced to conduct a complaint investigation. LPA met with Administrator Maria Ciscoe and stated the purpose of the visit.

Regarding the allegation of Staff did not maintain a comfortable temperature in the facility, the Department found the following: based on observation and interview the facility temperature ranged from 73 degrees to 75 degrees. LPA entered Resident 1's (R1) room and the temperature was adequate. LPA then interviewed Resident 2 ( R2) who stated that the facility and his/her room temperature was just fine.

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.

Unsubstantiated

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: 11/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2021

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 3

Control Number 27-AS-20211105120333

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: 11/10/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed Type B 11/10/2021 Section Cited CCR 87303(i)(1)(A)	1 2 3 4 5 6 7	Maintenance and Operation Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: (A) Operate from each resident's living unit. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator has fixed R1's call button while LPA was at the facility.
	8 9 10 11 12 13 14	Based on observation and interview this facility did not maintain compliance as evidenced by the call button in R1's room 143 not in proper functioning order. This poses a potential threat to the Health, Safety, and Personal Rights of all residents 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: 11/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2021

LIC9099 (FAS) - (06/04)

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