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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700301
Report Date: 12/30/2020
Date Signed: 01/08/2021 09:34:30 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
05/18/2020 and conducted by Evaluator Jasmine McCrory
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20200518112106
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 mishandled resident's medications.
INVESTIGATION FINDINGS:
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This document has been amended.
At 8:15 AM, Licensing Program Analyst (LPA) 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 not qualified to distribute medication. The allegation also indicates medications were administered to residents by staff that had not completed training and were unexperienced and that this happened as a result of short staffing.

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. (CONT)
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 5
Control Number 27-AS-20200518112106
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 mismanagement 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, states that Admin Ciscoe is searching for a medication tech from current care aide staff.

Based on interviews, observation, and record review, the LPA finds the allegation of Staff mishandled resident's medications. 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.

The following deficiency is being cited on the attached LIC 9099-D.


(CONT)
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 5
Control Number 27-AS-20200518112106
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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1569.69 (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:1) In facilities licensed to provide care for 16 or more persons, the employee shall complete 24 hours of initial training.
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An informal meeting was held via Zoom on 06/12/2020 with facility staff and CCL, in addition to the items agreed at that time the licensee agrees to create a training plan for staff who will handle medications to ensure proper training is completed before they begin administering medications.
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This training shall consist of 16 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications (...).
This is not evidenced based on records reviewed, the facility did not ensure qualified assistance was given to Residents.
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HSC
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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 5
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
05/18/2020 and conducted by Evaluator Jasmine McCrory
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20200518112106

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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Personal Rights
Insufficient staffing
INVESTIGATION FINDINGS:
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At 8:15 AM, Licensing Program Analyst (LPA) 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 allegations of Personal Rights and Insufficient Staffing.

Based on interviews and observations the LPA finds this allegations to be (U) UNSUBSTANTIATED. This agency has investigated the above listed allegations. Although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred therefore, we have found the allegation(s) to be UNSUBSTANTIATED. (CONT)
Unsubstantiated
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: 4 of 5
Control Number 27-AS-20200518112106
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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Based on interviews and observations during the tele-visit on 08/21/2020, the LPA finds this allegation to be (U) UNSUBSTANTIATED. This agency has investigated the above listed allegation. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred therefore, we have found the allegation(s) to be UNSUBSTANTIATED.


An exit interview was conducted with Admin Maria Ciscoe via telephone and a copy of this report will be
provided to the facility via United States Postal Service and email. Two copies will be sent to the facility, 1 is to be signed and returned to Community Care Licensing (CCL) and the other copy is to be retained by the facility.
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: 5 of 5