342700301-7-12-2023-27-AS-CACL-CTXSY5-20230721141658

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700301
Report Date: 07/12/2023
Date Signed: 07/12/2023 02:30:41 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
04/13/2023 and conducted by Evaluator Ruth Wallace

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20230413070003

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:	07/12/2023
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Mary Lindgren - Business Office Manager		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility did not assist resident with prescribed medication

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced facility visit to complete and delivery finding for a complaint investigation received on 4/13/2023. LPA met business office manager and discussed the conclusion for complaint and the finding. Business office manager notified licensee of visit.

During the investigation, LPA reviewed documents including, but not limited to resident file (R1);
Medical Records, Physician Reports, Medication Administration Records (MARS), Staff Phone Numbers, and Centrally Stored Medication Logs. LPA interviewed licensee, staff (S1-S4) and residents (R1-R4).
This allegation pertained to R1 and medications in question and is a duplicate. LPA Johnson substantiated Staff mismanaging resident medication on 4/6/2023 by Complaint Control Number: 27-AS-20230224163937
No deficiency or plan of correction is being cited per Title 22, Division 6 of the California Code of Regulations.

Exit interview was conducted with business office manager. A copy of the 9099 and 9099-C, LIC 811 (Confidential Names), and appeal rights were provided to the facility.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth Wallace	TELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2023

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

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
04/13/2023 and conducted by Evaluator Ruth Wallace

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20230413070003

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:	07/12/2023
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Mary Lindgren - Business Office Manager		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility failed to communicate with Conservator/responsible party
Facility denied resident right to choose own pharmacy
Facility failed to assist resident with medical care
Facility did not provide responsible party resident records upon request.
Facility failed to notify responsible party of change in condition

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced facility visit to complete and delivery findings for a complaint investigation received on 4/13/23. LPA met Administrator and discussed the conclusion for complaint and the findings.

During the investigation, LPA reviewed documents including, but not limited to resident file (R1),
Medical Records, Physician Reports, Medication Administration Records (MARS), Staff Phone Numbers, and Centrally Stored Medication Logs. LPA interviewed licensee, staff (S1-S4) and residents (R1-R4).

Through interview process and record review at facility, LPA did not find that facility failed to communicate with conservator/responsible party. LPA reviewed power of attorney (POA) changes in pharmacy and reoccurring monthly automatic withdrawals which shows residents or POA’s would have been notified of pharmacy change.
Continued on 9099-C Page 2

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth Wallace	TELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 27-AS-20230413070003

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: 07/12/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continued from 9099 - Page 2

Based on LPA review of resident (R1's) file, communication documentation, and medication chart. The change was completed approximately in the month of July 2022 with verbal approvals, not written. All power of attorneys (POA's) or residents had to set up reoccurring credit care approval for charges with pharmacy, so they would have been aware and notified.

Based on LPA review of R1’s admissions agreement which states all excluded services like laboratory services; the facility is not responsible for services. Therefore, the facility did not fail to assist resident with medical care.

Based on LPA review of R1’s resident records and correspondence, LPA did not find responsible party not being notified for resident records that are allowed to be released. Therefore, the facility did provide responsible party resident records upon request.

Based on LPA review of R1’s resident records and medication records. LPA did not find anything indicating a change in condition that facility would need to notify responsible party. Therefore, facility did not fail to notify responsible party of change in condition.

As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED.
Due to the above noted information, although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, and therefore the allegations are unsubstantiated.

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit.

An exit interview was conducted with business office manager. A copy of the 9099 and 9099-C, LIC 811 (Confidential Names), and appeal rights were provided to the facility.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth Wallace	TELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3