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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700301
Report Date: 12/30/2020
Date Signed: 12/31/2020 09:35:07 AM



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
06/08/2020 and conducted by Evaluator Jasmine McCrory
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20200608142340
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:
12/30/2020
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Maria Ciscoe, AdministratorTIME COMPLETED:
09:00 AM
ALLEGATION(S):
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Staff mismanaging resident's 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 mismanaging resident's medications.

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. (continued)

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jasmine McCroryTELEPHONE: (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)
Page: 1 of 3
Control Number 27-AS-20200608142340
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.

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 MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jasmine McCroryTELEPHONE: (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)
Page: 2 of 3
Control Number 27-AS-20200608142340
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
HSC
1569.69
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HSC 1569.69 Employees assisting residents with self-administration of medication; training requirements
(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:
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An informal meeting was held on 06/12/2020 with facility staff and CCL. In addtion to the items agreed upon at that time the licensee agrees to create a trainig plan for staff who will handle medication to ensure proper training is completed before staff begin to administer medication to residents.
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This requirement was not met as evidenced by interviews and documentation review. The licensee failed to comply with the regulation mentioned above.
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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: Jasmine McCroryTELEPHONE: (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