342700301-8-8-2023-27-AS-KHOS-CVDHLC-20230905061719

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700301
Report Date: 08/08/2023
Date Signed: 08/08/2023 05:16:33 PM

Unsubstantiated

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
05/12/2023 and conducted by Evaluator Kevin Gould

COMPLAINT CONTROL NUMBER: 27-AS-20230512124618

FACILITY NAME:	COUNTRY CLUB MANOR		FACILITY NUMBER:	342700301
ADMINISTRATOR:	STONSBY, ELIZA		FACILITY TYPE:	740
ADDRESS:	2100 BUTANO DRIVE		TELEPHONE:	(916) 481-9240
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95825
CAPACITY:	112	CENSUS: 57	DATE:	08/08/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:			TIME COMPLETED:	05:16 PM

ALLEGATION(S):

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Personal Rights:
1) Staff are not providing adequate care and supervision to a resident

Medication
1) Staff are mishandling a resident's medication

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kevin Gould made an unannounced inspection to Country Club Manor (RCFE) on 8/8/23 at 9:00am to conclude the investigation of the above allegations and to deliver the findings. LPA met with staff and together discussed the investigation details.

Based on the interviews and statements obtained during the investigation process, the allegations cannot be substantiated. Regarding Medication, LPA reviewed resident's medication log and observed no irregularities. LPA conducted interview with resident who expressed concern the staff were still using an old prescrition when a new medication had been filled (same medication). LPA explained to resident the staff are using her own existing supply and had ordered new medications before the current bottel had ended to ensure resident had enough medications. Resident understands and accepts this explanation of medication.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2023

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 4

Control Number 27-AS-20230512124618

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: 08/08/2023

NARRATIVE

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Regarding care and supervision, LPA conducted interviews with resident and 6 staff members. All staff members interviewed denied the call log system could be turned off. when reviewing the system with resident the computer at the front desk was misidentified as the call light system. Resident has diagnosis of MCI which may account for confusion regarding medications and call light system.

Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of medication and personal rights are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed.

There are no deficiencies noted or cited per California Code Regulation, TITLE 22.

Exit interview was conducted with the facility staff. Appeal Rights were issued, and a copy of this report was left at the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
05/12/2023 and conducted by Evaluator Kevin Gould

COMPLAINT CONTROL NUMBER: 27-AS-20230512124618

FACILITY NAME:	COUNTRY CLUB MANOR		FACILITY NUMBER:	342700301
ADMINISTRATOR:	STONSBY, ELIZA		FACILITY TYPE:	740
ADDRESS:	2100 BUTANO DRIVE		TELEPHONE:	(916) 481-9240
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95825
CAPACITY:	112	CENSUS: 57	DATE:	08/08/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:			TIME COMPLETED:	05:16 PM

ALLEGATION(S):

1
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7
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9

Personal Rights: Staff are mishandling a resident's confidential information while in care

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Kevin Gould made an unannounced inspection to Country Club Manor (RCFE) on 8/8/23 at 9:00am to conclude the investigation of the above allegations and to deliver the findings. LPA met with staff and together discussed the investigation details.

Based on the interviews conducted and statements obtained during the investigation process, the allegations cannot be corroborated because the resident did not have any reasonable basis for the allegation. LPA interviewed resident who states she was concerned regarding her confidential information because she received a letter from her bank in a different colored envelope. Per RP he has no knowleged of allegeld victim's care in the facility. RP states there have been no unauthorized changes to her banking and that no confidential information has been breeched per the bank. LPA reviewed resident record storage and observed all records to be locked and inacessible to most staff with exception of staff management and med techs.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2023

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

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 27-AS-20230512124618

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: 08/08/2023

NARRATIVE

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The Department has investigated the complaint alleging personal rights. Based on the investigative interviews, record reviews and other supportive evidence, the complaint is determined to be unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. The Complaint has been dismissed.

There are no deficiencies noted or cited per California Code Regulation, TITLE 22.

Exit interview was conducted with the facility staff. Appeal Rights were issued and a copy of this report was left at the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 4