342700301-4-12-2023-27-AS-KHOS-CQUKPP-20230413080504

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700301
Report Date: 04/06/2023
Date Signed: 04/12/2023 10:18:41 AM

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
02/24/2023 and conducted by Evaluator Albert Johnson

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20230224163937

FACILITY NAME:	COUNTRY CLUB MANOR		FACILITY NUMBER:	342700301
ADMINISTRATOR:	VENEGAS, MARICAR		FACILITY TYPE:	740
ADDRESS:	2100 BUTANO DRIVE		TELEPHONE:	(916) 481-9240
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95825
CAPACITY:	112	CENSUS: 58	DATE:	04/06/2023
		UNANNOUNCED	TIME BEGAN:	12:55 PM
MET WITH:	Mary Lungren and Robert Godfrey, Regional Director of Operations		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff mismanaged resident medication

INVESTIGATION FINDINGS:

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LPA Johnson arrived unannounced to complete the investigation of the above allegation.

Based on records reviewed the facility did not follow the doctors order for R1's medication. On 11/10/2020 the facility noted on the medication administration record that medication (Rivaroxaban) for R1 was discontinued. The previous records indicated that the medication was not started or refilled, because the resident's insurance did not cover the medication.

It was discovered by this LPA that the facility has no record to confirm that the medication was discontinued by the Primary Care Physician, LPA was able to confirm through records review that the medication in question was attempted to be refilled on multiple occasions, however, the record show that the medication in question was not covered by the residents insurance and a requested was made to have an alternative medication in-place of the non-covered medication.

Substantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert Johnson	TELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023

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-20230224163937

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: 04/06/2023

NARRATIVE

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On 11/28/2021, the doctor addressed the void and ordered the replacement medication (Eliquis), It was not started until February 22, 2023.

R1 was without the prescribed medication from July 1, 2020 until February 22, 2023. The replacement medication (Eliquis) was started on February 22, 2023, the family became aware after reviewing the medications list that R1 had not been taking the medication (Rivaroxaban) for the above time period.

The Licensee and Resident Care Coordinator responsible at the time of the error are no longer employed.

Based on records reviewed 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 9099 D during this visit. Exit interview held, Appeal Rights discussed and given, Copy of report given.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert Johnson	TELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 27-AS-20230224163937

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: 04/06/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type B 04/07/2023 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	Incidental Medical and Dental Care. (a) A plan for incidental medical and dental care shall be developed by each facility...(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not as evidenced by:	1 2 3 4 5 6 7	Licensee/Administrator will provided additional staff inservice on medication administration and will provide proof of completed in-service to LPA by POC due date.
	8 9 10 11 12 13 14	Licensee did not ensure a proper medication order was followed for R1. This posed an immediate health and safety risk to resident in care.	8 9 10 11 12 13 14	The Licensee and Resident Care Coordinator responsible at the time of the error are no longer employed.
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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: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert Johnson	TELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023

LIC9099 (FAS) - (06/04)

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