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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700301
Report Date: 02/12/2021
Date Signed: 02/12/2021 04:18:58 PM

Substantiated


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
12/11/2020 and conducted by Evaluator Danyle Wolter
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20201211155542
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: 49DATE:
02/12/2021
UNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Maria Ciscoe, administratorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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facility is incorrectly billing responsible party for rent invoices already paid
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Wolter contacted the administrator, Maria Ciscoe via phone due to COVID-19 and precautionary measures to deliver complaint findings for the allegation listed above, LPA explained the purpose of the call.

Throughout the course of the investigation LPA conducted interviews and reviewed documentation relevant to the allegation: facility is incorrectly billing responsible party for rent invoices already paid. In interviews with administrator it was discovered that the responsible party was incorrectly billed.

Due to this information the complaint is found to be (S) SUBSTANTIATED - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met: Refer to the 9099-D for citation.

Exit interview conducted. A copy of report and appeal rights were emailed to administrator. A signed copy is to be returned to the department by either email, fax, or USPS. Facility should maintain a signed copy for their records.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Danyle WolterTELEPHONE: (916) 708-5307
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2021
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 2
Control Number 27-AS-20201211155542
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: 02/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
02/26/2021
Section Cited
CCR
87507(f)
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87507 Admission Agreements
(f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments.
This requirement was not met as evidenced by: interviews and documentation review. The responsible party was incorrectly billed for
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Administrator has already implemented a plan to address this issues from occurring in the future by pulling invoices and reviewing them for accuracy before they are sent to families. Written statement of this practice and implementation to be sent to CCL by 2/26/2021.
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invoices already paid, which is not consistent with facilities admission agreement. This poses a potential health and safety risk to residents in care.
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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 MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Danyle WolterTELEPHONE: (916) 708-5307
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2021
LIC9099 (FAS) - (06/04)
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