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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700301
Report Date: 08/06/2026
Date Signed: 08/10/2026 03:37:33 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/17/2026 and conducted by Evaluator Avelina Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20260417151128
FACILITY NAME:COUNTRY CLUB MANORFACILITY NUMBER:
342700301
ADMINISTRATOR:KATHRYN NEVINFACILITY TYPE:
740
ADDRESS:2100 BUTANO DRIVETELEPHONE:
(916) 481-9240
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:112CENSUS: 59DATE:
08/06/2026
UNANNOUNCEDTIME BEGAN:
02:06 PM
MET WITH:Kathryn Nevin TIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
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9
Staff mismanaged resident's medications
Staff stole from residents in care
INVESTIGATION FINDINGS:
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On August 06, 2026, at 2:06 PM, Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced to deliver complaint findings. LPA Martinez met with Kathryn Nevin during today’s visit and explained the purpose of the visit.

Throughout the course of this investigation, LPA Martinez conducted interviews, reviewed facility records, and reviewed resident records. Based on resident 1's (R1) medication administration record review and file review, there was no evidence to show that R1 was administered the wrong medication. R1 also reported that they have not been administered the wrong medication. Additionally, facility records show that facility staff were managing R1's refill requests, and contacting R1's primary physician to obtain medication in a timely manner. Five out of six staff reported there have been no medication errors.

Continued...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Arielle Pascua
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2026
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 2
Control Number 27-AS-20260417151128
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: COUNTRY CLUB MANOR
FACILITY NUMBER: 342700301
VISIT DATE: 08/06/2026
NARRATIVE
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In addition, LPA Martinez interviewed five out of five residents. Four out five residents reported that none of their property have been stolen by staff. One out of five residents informed LPA Martinez that they did not want to be interviewed. Six out of six staff reported that they are not aware of staff stealing from residents.

Due to the above noted information, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, and therefore the allegations are unsubstantiated. An exit interview was conducted, and a copy of this report was provided to the facility.
SUPERVISORS NAME: Arielle Pascua
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 2