342700301-12-30-2020-27-AS-KHOS-BX2LGX-20210107074528

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700301
Report Date: 12/30/2020
Date Signed: 12/30/2020 03:16:44 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
05/15/2020 and conducted by Evaluator Jasmine McCrory

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20200515160602

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: 49	DATE:	12/30/2020
		UNANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:	Administrator Maria Ciscoe		TIME COMPLETED:	09:00 AM

ALLEGATION(S):

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Staff not qualified to distribute medication

INVESTIGATION FINDINGS:

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At 8:15 AM, Licensing Program Analyst (LPA) Jasmine McCrory contacted the facility via telephone to deliver complaint findings for the above allegation. Findings are delivered via telephone due to COVID-19 pre-cautionary measures. LPA explained the purpose of the call to Administrator (Admin) Maria Ciscoe.

During the investigation, LPA interviewed facility staff and relevant parties, and obtained documentation pertinent to the investigation of the allegation that Staff is not qualified to distribute medication. The allegation also indicates medications were administered to residents by staff that had not completed training and were unexperienced and that this happened as a result of short staffing.

During interviews, Admin Ciscoe admitted she lost caregivers due to a fear of COVID-19 and she is doing her best to ensure there are enough caregivers on the floor every shift to meet the needs of the residents. The administrator stated that she has asked caregivers to work 12-hours temporarily as she interviews, hires, and trains new caregivers. (CONT)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jasmine McCrory	TELEPHONE: (916) 214-5020
LICENSING EVALUATOR SIGNATURE:	DATE: 12/30/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2020

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-20200515160602

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: 12/30/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/30/2020 Section Cited ILS 1569.69(a)(1)	1 2 3 4 5 6 7	1569.69 (a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements:1) In facilities licensed to provide care for 16 or more persons, the employee shall complete 24 hours of initial training.	1 2 3 4 5 6 7	An informal meeting was held via Zoom on 06/12/2020 with facility staff and CCL, in addition to the items agreed at that time the licensee agrees to create a training plan for staff who will handle medications to ensure proper training is completed before they begin administering medications.
	8 9 10 11 12 13 14	This training shall consist of 16 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications (...). This is not evidenced based on records reviewed, the facility did not ensure qualified assistance was given to Residents.	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: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jasmine McCrory	TELEPHONE: (916) 214-5020
LICENSING EVALUATOR SIGNATURE:	DATE: 12/30/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2020

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 27-AS-20200515160602

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: 12/30/2020

NARRATIVE

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LPA reviewed an Unusual Incident/Injury Report (LIC 624) dated 05/09/2020 submitted by Administrator Maria Ciscoe regarding medication mis-management on two different days. The LIC 624 reflects two mismanagements on 05/22/2020 and one mismanagement on 05/25/2020. Due to employee call-offs and employee suspensions the medications were not pre-poured or passed. Also, Admin Ciscoe states she is searching for a medication tech from current care aide staff.

LPA requested the Personnel Reports (LIC 500) from Admin Ciscoe along with verification of trainings. These documents were received on 07/03/2020 and 07/06/2020. Upon review, the LIC 500 listed 17 staff as Med Aides or Med Techs. 7 out of the 17 staff listed had Medication Training verifications.

Based on interviews, observations, and record review, LPA McCrory finds preponderance of evidence standards has been met, and therefore the above allegation to be (S) SUBSTANTIATED. Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D page.

An exit interview was conducted with Administrator Maria Ciscoe and a copy of this report and Appeal Rights will be provided to the facility via email. Administrator Maria agrees to sign and return a copy of the report to Community Care Licensing (CCL) and keep a copy for facility records.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jasmine McCrory	TELEPHONE: (916) 214-5020
LICENSING EVALUATOR SIGNATURE:	DATE: 12/30/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2020

LIC9099 (FAS) - (06/04)

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