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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700301
Report Date: 10/31/2023
Date Signed: 10/31/2023 03:14:34 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
08/31/2023 and conducted by Evaluator Pang Lee
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230831114400
FACILITY NAME:COUNTRY CLUB MANORFACILITY NUMBER:
342700301
ADMINISTRATOR:FOZ, ROMERICOFACILITY TYPE:
740
ADDRESS:2100 BUTANO DRIVETELEPHONE:
(916) 481-9240
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:112CENSUS: 59DATE:
10/31/2023
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Editha Mccullough and Sara NicholsTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff did not ensure that facility trash bin lids are tightly secured.
Staff financially abused residents in care.
Unqualified staff are administering medications to residents.
Staff is not ensuring that resident is dressed in clean clothing
INVESTIGATION FINDINGS:
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On 10/31/2023 at 12:15 PM Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with Interim Resident Coordinator, Editha Mccullough and Resident Care Coordinator, Sarah Nichols and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegations above. The current census is 59. A brief interview with conducted with Editha Mccullough and Sara Nichols.

LPA Lee toured the facility at 2:00 PM, and observed resident in the living room with a guest singer and his guitar singing. Drinks and snacks was offered to residents. The living room was filled with residents. Residents appeared to be in clean clothing and enjoyed the guest singer and each other.

Allegation: Staff did not ensure that facility trash bin lids are tightly secured.
It was alleged that staff did not ensure that facility trash bin lids are tightly secured. This investigation consisted of observations and interviews with staff and residents
Continued LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023
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 6
Control Number 27-AS-20230831114400
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: 10/31/2023
NARRATIVE
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LPA Lee interviewed 10 out of 10 residents and it was learned that 6 out of 10 residents had no concerns with the facility trash bin lids are not tightly secured. Furthermore, 6 out of 10 residents have not witnessed other residents digging through the facility garbage. During complaint investigation visit on 09/07/2023 and 10/09/2023 LPA Lee did observe one garbage in the sun room, one garbage in the activity room, one garbage in the front entry of the facility, one garbage in the dining room and three big garbage in the hallway. All the garbage’s observed on both days throughout the facility had fitted tight lids on them. Furthermore, LPA Lee did not observe any residents digging through the facility trash bins.

Based on information provided through interviews, observations and records reviewed, the allegation is deemed UNSUBSTANTIATED although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation staff did not ensure that facility trash bin lids are tightly secured.

Allegation: Staff financially abused residents in care.

It was alleged that staff financially abused residents in care. This investigation consisted of records review and interviews with staff and residents. LPA Lee interviewed 10 out of 10 residents and it was learned 10 out of 10 residents have no concern and have not experienced or witness staff financially abused resident in care. Throughout the investigation it was learned that the resident will pay rent by writing a check and then giving the check to the front desk. The front desk then gives the resident a receipt and makes a copy of the resident check and file for record. The front desk then drops the checks into the office locked box. Regional Director Robert Godfrey then picks up the check from the locked box in the office. Furthermore, 5 out of 5 facility staff denies staff are financially abusing residents in care.

Based on information provided through interviews and records reviewed, the allegation is deemed UNSUBSTANTIATED although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation staff financially abused resident in care.



Allegation: Unqualified staff are administering medications to residents.

It was alleged that unqualified staff are administering medications to residents. This investigation consisted of records review and interviews with staff and residents. LPA Lee interviewed 10 out of 10 residents and it was learned 6 out of 10 residents are receiving their prescribed medications and have no concerns. LPA Lee also reviewed 3 facility Med-Tech facility files and training records. It was learned that 3 out of 3 Med-Techs files are complete and has the required training documented in their files.

Continued LIC 9099-C

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 27-AS-20230831114400
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: 10/31/2023
NARRATIVE
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Based on information provided through interviews and records reviewed, the allegation is deemed UNSUBSTANTIATED although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation staff is not ensuring that resident is dressed in clean clothing.

Allegation: Staff is not ensuring that resident is dressed in clean clothing

It was alleged that the staff is not ensuring that residents are dressed in clean clothing. This investigation consisted of observations and interviews with staff and residents. LPA Lee interviewed 10 out of 10 residents and it was learned that 10 out of 10 residents had no concerns with the staff not ensuring that resident is dressed in clean clothing. Ten residents that were interviewed were observed to be in clean clothing. Furthermore, during the complaint investigation visit on 09/07/2023, 10/09/2023 and 10/31/2023 LPA Lee did not observe any resident in dirty or unclean clothing.

Based on information provided through interviews and records reviewed, the allegation is deemed UNSUBSTANTIATED although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation staff is not ensuring that resident is dressed in clean clothing.



An exit interview was conducted with Editha Mccullough and Sara Nichols and a copy of this report was given to Editha Mccullough and Sara Nichols.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
08/31/2023 and conducted by Evaluator Pang Lee
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230831114400

FACILITY NAME:COUNTRY CLUB MANORFACILITY NUMBER:
342700301
ADMINISTRATOR:FOZ, ROMERICOFACILITY TYPE:
740
ADDRESS:2100 BUTANO DRIVETELEPHONE:
(916) 481-9240
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:112CENSUS: 59DATE:
10/31/2023
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Editha Mccullough and Sara NicholsTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility administrator is not on the premises for a sufficient number of hours.
Staff did not ensure that resident's are eating meals.
INVESTIGATION FINDINGS:
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On 10/31/2023 at 12:15 PM Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with Interim Resident Coordinator, Editha Mccullough and Resident Care Coordinator, Sarah Nichols and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegations above. The current census is 59. A brief interview with conducted with Editha Mccullough and Sara Nichols.

Allegation: Facility administrator is not on the premises for a sufficient number of hours.
It was alleged that the Facility administrator was not on the premises for a sufficient number of hours. This investigation consisted of records reviewed, interviews with staff, and residents. LPA Lee interviewed 10 out of 10 residents and it was learned that 4 out of 10 residents don’t know who the administrator is and 6 out of 10 residents doesn’t see administrator at the facility for sufficient number of hours. Furthermore, it was also learned from 5 out 5 facilities staff that the administrator is at the facility 3 times per week.
Continued LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023
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 6
Control Number 27-AS-20230831114400
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: 10/31/2023
NARRATIVE
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 Per facility, LIC 500 Personnel Report it shows that administrator, Rico Foz is at the facility from Monday to Friday from 9:00 AM to 5:30 PM. On 09/07/2023 LPA Lee was at the facility from 9:44 AM to 3:40 PM and did not see administrator at the facility; therefore, the facility is not adhering to facility LIC 500 Personnel Report.

As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met

Allegation: Staff did not ensure that residents were eating meals.

It was alleged that the staff did not ensure that residents were eating meals. This investigation consisted of recorded reviews and observations and interviews with staff and residents. LPA Lee interviewed 10 out of 10 residents and it was learned that 5 out of 10 residents did not receive their meals delivered to their room when residents don’t come to the dining room. Throughout the investigation, it was learned that residents go to the dining room for all meals. It was also learned that residents can choose to pick up their meals and eat in their room or if resident choose to have meal deliver to their room with no fees. LPA Lee reviewed meal logs and record review revealed that on 09/06/2023 meal logs, 6 breakfast was left black, 3 lunch was left blank and 1 dinner was also left blank. On 09/07/2023, meal logs 5 breakfast was left blank and 2 lunch was left blank. On 10/27/2023 meal logs, 1 breakfast was left blank, 1 lunch was left blank and 66 dinner was left blank. Moreover, on 10/30/2023, meal logs 7 breakfast was left blank, 5 lunch was left blank and 68 dinner was also left blank; therefore, it is unclear if the residents received their meals.

As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with Editha Mccullough and Sara Nichols and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility.


SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 27-AS-20230831114400
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/10/2023
Section Cited
CCR
87405(a)
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87405(a) Administrator - Qualifications and Duties
(a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours…

This requirement is not met as evidenced by:
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Administrator agrees to read regulation 87405(a) and submit a signed declaration of understanding. The administrator will review LIC 500 Personnel Report for accuracy and ensure the administrator is present at the facility for a sufficient number of hours. The administrator will email POC to LPA Lee by POC due date 11/10/2023 by 5:00 PM end of day (pang.lee@dss.ca.gov)
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Based on interviews, records review and observations, the licensee did not comply with the section cited above. The administrator did not ensure that administrator is at the facility for sufficient number of hours, which poses/posed a potential health, safety or personal rights to person in care.

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Type B
11/10/2023
Section Cited
CCR
87555(b)(1
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87555(b)(1) General Food Service Requirements
(b) The following food service requirements shall apply:

(1) Where all food is provided by the facility arrangements shall be made so that each resident has available at least three meals per day. Exceptions may be allowed on weekends and holidays providing the total daily food needs are met. Not more than fifteen (15) hours shall elapse between the third and first meal.

This requirement is not met as evidenced by:
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Administrator agrees to read regulation 87555(b)(1) and submit a signed declaration of understanding. The administrator will audit meal logs and ensure that all residents are receiving breakfast, lunch and dinner at all times. The administrator will email POC to LPA Lee by POC due date 11/10/2023 by 5:00 PM end of day (pang.lee@dss.ca.gov)
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Based on interviews and records review the administrator did not comply with the section cited above. The licensee did not ensure that resident is provided with three meals per day. Meal logs reviewed reveals discrepancies; therefore, it is unclear if residents received their meals.
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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: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6