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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700301
Report Date: 02/23/2021
Date Signed: 02/23/2021 12:52:45 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
07/30/2020 and conducted by Evaluator Danyle Wolter
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20200730163451
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: 48DATE:
02/23/2021
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Maria Ciscoe, administrator TIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff not properly trained.
Facility failed to safeguard residents belongings.
Facility violated residents personal rights.
Administrator qualifications.
Cleaning supplies not locked up.
Facility failed to communicate residents change in condition.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Wolter contacted the facility via phone on 2/23/2021 to deliver complaint findings due to COVID-19 and precautionary measures, LPA spoke to administrator Maria Ciscoe and explained the purpose of the call.

Throughout the course of the complaint investigation the department conducted interviews and reviewed documentation relevant to the allegations: staff not properly trained, facility failed to safeguard residents belongings, facility violated residents personal rights, cleaning supplies not locked up, facility failed to communicate residents change in condition, and administrator qualifications.

Report continued on LIC 9099-C
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: 02/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 11
Control Number 27-AS-20200730163451
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: 02/23/2021
NARRATIVE
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In interviews with facility staff the department was told that there were times R1 would not receive medications because the facility had “run out” of the medication. Documentation reviewed revealed that medication administered to R1 was not always properly documented and that there were dates R1 missed scheduled medications due to the facility having ran out of the resident’s medication and not ordering refills in time. The department was told that it is facility policy to initial the medication administration record (MAR) after medication is administered and to ensure that scheduled medication is refilled, in interviews with facility staff it was disclosed that there was either mis-communication about who was to reorder prescriptions, or it was an error on the facilities part.

Due to this information the allegation: staff not properly trained is found to be (S) SUBSTANTIATED - A finding that the allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

The following deficiency is cited on the attached LIC 9099-D:
87465 Incidental Medical and Dental Care
(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (5) The licensee shall assist residents with self administered medications as needed.

The department revealed R1’s records and found in Appendix I (Country Club Manor Resident Personal Property Policies) of the residence and care agreement - assisted living, to state that, “Country Club Manor will maintain an inventory of all personal property items of $25 or more in value, as identified by resident.” A review of R1’s records found that an LIC 621 – Client/Resident Personal Property and Valuable was incomplete and not signed by the resident or responsible party.

Due to this information the allegation: facility failed to safeguard residents belongings is found to be (S) SUBSTANTIATED - A finding that the allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Report continued on LIC 9099-C
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Danyle WolterTELEPHONE: (916) 708-5307
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 11
Control Number 27-AS-20200730163451
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: 02/23/2021
NARRATIVE
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The following deficiency is cited on the attached LIC 9099-D:
87217 Safeguards for Resident Cash, Personal Property, and Valuables
(g) Each licensee shall maintain adequate safeguards and accurate records of cash resources and valuables entrusted to his care, including, but not limited to the following: (2) Records of residents' cash resources and other valuables entrusted to the licensee for safekeeping shall include a copy of the receipt furnished to the resident as specified in (b) above or to his responsible person. The receipt provided to the resident for money or valuables entrusted to the licensee shall be original and include the resident's and/or his responsible person's signature.

In interviews with facility staff and a witness (W1) regarding the facilities visitor policy during the pandemic the department was told that the facility was to screen visitors prior to visits taking place. In an interview with W1 the department was told that on July 3, 2020 they were able to check-in at the receptionist and go to R1’s room without being screened. No visitor logs were available for review from that time.

Due to this information the allegation: Facility violated residents personal rights is found to be (S) SUBSTANTIATED - A finding that the allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

The following deficiency is cited on the attached LIC 9099-D:
§1569.269 Enumerated rights; severability
(a) Residents of residential care facilities for the elderly shall have all of the following rights:
(5) To be accorded safe, healthful, and comfortable accommodations, furnishings, and equipment.

The department was told by a witness (W2) that cleaning supplies were being left unlocked and accessible to residents at the facility. In interviews with staff the department was told that there are times that family members will bring in cleaning supplies to residents and they have to be removed but that otherwise cleaning supplies are supposed to be locked up. In an interview with staff (S1) the department was told that cleaning supplies have been found to be unlocked on cleaning carts at various times.

Report continued on LIC 9099-C
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Danyle WolterTELEPHONE: (916) 708-5307
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 11
Control Number 27-AS-20200730163451
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: 02/23/2021
NARRATIVE
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Due to this information the allegation: cleaning supplies not locked up is found to be (S) SUBSTANTIATED - A finding that the allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

The following deficiency is cited on the attached LIC 9099-D:
87309 Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

The department was told by W2 that R1 experienced a change in condition that was not communicated to the responsible party. In interviews with staff the department was told that R1 was becoming more forgetful and had experienced falls while in the assisted living side of the community, it was also discovered that an incident occurred where R1 attempted to take a shower unsupervised and flooded the hallway. Review of incident reports from 2020 revealed that none of these incidents were reported to licensing. A review of R1’s care notes do not reference the increase in dementia behaviors or indicate that R1’s responsible party or doctor were notified.

Due to this information the allegation: Facility failed to communicate residents change in condition is found to be (S) SUBSTANTIATED - A finding that the allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

The following deficiencies are cited on the attached LIC 9099-D:
87466 Observation of the Resident
The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.

Report continued on LIC 9099-C
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Danyle WolterTELEPHONE: (916) 708-5307
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2021
LIC9099 (FAS) - (06/04)
Page: 10 of 11
Control Number 27-AS-20200730163451
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: 02/23/2021
NARRATIVE
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87211 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.

Throughout the course of this investigation the qualifications of the administrator were reviewed, it was found that facility policies that are in place are not adequately being following, this is evidenced by the MAR not being completed properly, medications not being refilled timely, COVID-19 Visitor Policy not being followed, and reporting requirements not being followed.

Due to this information the allegation: Administrator qualifications is found to be (S) SUBSTANTIATED - A finding that the allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

The following deficiency is cited on the attached LIC 9099-D:
87405 Administrator - Qualifications and Duties
(h) The administrator shall have the responsibility to: (4) Recruit, employ and train qualified staff, and terminate employment of staff who perform in an unsatisfactory manner.

Exit interview conducted. A copy of the report and appeal rights were emailed to administrator, administrator to return a signed copy of the report either by email, fax, or USPS. A signed copy should be retained for facility records as well.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Danyle WolterTELEPHONE: (916) 708-5307
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2021
LIC9099 (FAS) - (06/04)
Page: 9 of 11
Control Number 27-AS-20200730163451
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: 02/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
02/24/2021
Section Cited
CCR
87309(a)
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87309 Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
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Licensee to hold an in-service training with all staff about ensuring that cleaning supplies are kept locked and inaccessible. Training to be scheduled by 2/24/2021. A copy of sign-in sheet and training materials to be provided to CCL once training complete.
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This requirement was not met as evidenced by: interviews. The licensee failed to comply with the regulation referenced above. Interviews revealed that cleaning supplies have been found unlocked at the facility. This poses an immediate health and safety risk to residents in care.
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Staff to sign a statement of understanding that cleaning supplies are to be kept inaccessible to residents in care, copy to be kept in staff files and sent to CCL by 3/9/2021.
Request Denied
Type A
02/24/2021
Section Cited
CCR
87466
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87466 Observation of the Resident
The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning [...] When changes such as [...] deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the
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Licensee to review regulation and write a letter of understanding that changes in condition are to be documented and brought to the attention of the resident’s physician and responsible party. Letter to include plan of how observations will be documented. Proof of correction due by 2/24/2021.
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attention of the resident's physician and the resident's responsible person, if any.
This requirement was not met as evidenced by: interviews and documentation. The licensee failed to comply with the regulation referenced above. Interviews revealed that R1 had increasing dementia behaviors, [see box right]
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there is no documentation that the responsible party or the doctor were notified. This poses an immediate health and safety risk to residents in care.
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: 02/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 11
Control Number 27-AS-20200730163451
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: 02/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/09/2021
Section Cited
CCR
87465(a)(5)
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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. [...] (5) The licensee shall assist residents with self-administered medications as needed.
This requirement was not met as evidenced by: documentation and interviews.
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Licensee agrees to conduct an audit of all resident medications to ensure that medication is ordered timely and available on hand. Additionally, licensee to create a process for ensuring medication refills are ordered timely, a copy of the process to be sent to CCL by 3/9/2021.
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The licensee failed to comply with the regulation referenced above. Interviews and documentation reviewed revealed that the facility did not ensure they assisted R1 with medications as prescribed by the physician. This poses a potential health and safety risk to residents in care.
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Audit to be scheduled by 3/9/2021, findings of the audit to be sent to CCL once completed but no later than 3/23/2021.
Deficiency Dismissed
Type B
03/09/2021
Section Cited
CCR
87217(g)(2)
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87217 Safeguards for Resident Cash, Personal Property, and Valuables
(g) Each licensee shall maintain adequate safeguards and accurate records of cash resources and valuables entrusted to his care, including, but not limited to the following: (2) Records of residents' cash resources and other valuables [...]
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Licensee to audit all resident records to ensure that an LIC 621 is completed and signed. Letter of understanding that all residents should have a complete and signed LIC 621 to be sent to CCL by 3/9/2021.
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This requirement was not met as evidenced by: documentation review. The licensee failed to comply with the regulation referenced above. Documentation reviewed revealed that R1 did not have a complete nor signed LIC 621 in their records. 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: 02/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2021
LIC9099 (FAS) - (06/04)
Page: 11 of 11
Control Number 27-AS-20200730163451
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: 02/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/09/2021
Section Cited
HSC
1569.269(a)(5)
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§1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights:
(5) To be accorded safe, healthful, and comfortable accommodations, furnishings, and equipment.
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Licensee to conduct an in-service training to all receptionists covering facilities visitation plan. Any staff who cover the receptionist desk should be included in the in-service training. Training to be scheduled by 3/9/2021 and completed no later than 3/23/2021. Sign in sheet and documents to be sent to CCL by 3/23/2021.
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This requirement was not met as evidenced by: interviews. The licensee failed to comply with the health and safety code referenced above. Interviews revealed that a visitor was allowed to enter R1’s apartment without being screened during the pandemic. This poses a potential health and safety risk to residents in care.
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Request Denied
Type B
03/09/2021
Section Cited
CCR
87211(a)(1)(D)
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87211 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department [...] (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident [..] (D) Any incident which threatens the welfare, safety or health of any resident [...]
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Licensee to review regulation and send letter of understanding to CCL by 3/9/2021.
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This requirement was not met as evidenced by: interviews and documentation. The licensee failed to comply with the regulation referenced above. A review of facility records revealed that no incident reports were submitted for R1 in 2020. 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: 02/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 11
Control Number 27-AS-20200730163451
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: 02/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
03/09/2021
Section Cited
CCR
87405(h)(4)
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7
87405 Administrator - Qualifications and Duties (h) The administrator shall have the responsibility to: (4) Recruit, employ and train qualified staff, and terminate employment of staff who perform in an unsatisfactory manner.
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Licensee to review regulation and create a plan to ensure that administrator administers facility and trains staff regarding all applicable regulations and established policy. Plan due to CCL by 3/9/2021.
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This requirement was not met as evidenced by: interviews, documentation and compliance history. The licensee failed to comply with the regulation referenced above. Administrator failed to ensure that employees hired were qualified and trained to adequately assist residents. 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: 02/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 11
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
07/30/2020 and conducted by Evaluator Danyle Wolter
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20200730163451

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: DATE:
02/23/2021
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Maria Ciscoe, administratorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Facility failed to maintain physical plant.
Insufficient staffing to meet residents needs.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Wolter contacted the facility via phone on 2/23/2021 to deliver complaint findings due to COVID-19 and precautionary measures, LPA spoke to administrator Maria Ciscoe and explained the purpose of the call.

Throughout the course of the complaint investigation the department conducted interviews and reviewed documentation relevant to the allegations: Facility failed to maintain physical plant and Insufficient staffing to meet residents needs.

The department was told by W1 and W2 that at times R1’s room appeared to be cluttered and dirty, however in interviews with facility staff the department was told that R1’s room was cleaned regularly, and trash was taken out daily.

Report continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Danyle WolterTELEPHONE: (916) 708-5307
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 7 of 11
Control Number 27-AS-20200730163451
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: 02/23/2021
NARRATIVE
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R1’s individual plan of care dated 1/31/2020 was reviewed and interviews were conducted with staff, staff did not reveal that R1’s needs were not met due to insufficient staffing.

Due to this information the department finds the allegations to be UNSUBSTANTIATED - A finding that the allegations are unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted. A copy of the report and appeal rights were emailed to administrator, administrator to return a signed copy of the report either by email, fax, or USPS. A signed copy should be retained for facility records as well.

SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Danyle WolterTELEPHONE: (916) 708-5307
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2021
LIC9099 (FAS) - (06/04)
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