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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700301
Report Date: 11/10/2022
Date Signed: 11/10/2022 03:51:28 PM

Unfounded


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
11/08/2022 and conducted by Evaluator Christopher Hopkins-Clarke
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20221108110918
FACILITY NAME:COUNTRY CLUB MANORFACILITY NUMBER:
342700301
ADMINISTRATOR:VENEGAS, MARICARFACILITY TYPE:
740
ADDRESS:2100 BUTANO DRIVETELEPHONE:
(916) 481-9240
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:112CENSUS: 56DATE:
11/10/2022
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Maricar VenegasTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
-Staff allows resident to walk outside without shoes
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 11/10/2022 at 2:30PM, Licensing Program Analyst (LPA) Chris Hopkins arrived at this facility unannounced to conduct a complaint investigation regarding the above allegation. LPA met with Administrator Maricar Venegas and explained the purpose of today's visit.

Regarding the allegation Staff allows resident to walk outside without shoes, the Department found the following; based on interview, it was determined that Resident 1 (R1) did have on slippers while being outside. This may not have been the proper footwear but R1 did have on footwear.

We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

An exit interview was conducted, and a copy of this report was left at the facility.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2022
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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