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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700301
Report Date: 08/04/2026
Date Signed: 08/04/2026 11:35:51 AM

Unfounded


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
07/26/2026 and conducted by Evaluator Sulma Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20260726191356
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: 63DATE:
08/04/2026
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Kathryn NevinTIME COMPLETED:
12:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not abiding by the terms and conditions of Admission Agreement.
Staff do not ensure that resident's room is clean.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On August 4, 2026 at 11:30am, Licensing Program Analyst (LPA) Sulma Lopez and Licensing Program Manager (LPM) Arielle Pascua arrived unannounced at the facility to conduct a complaint investigation regarding the above allegations. LPA met with Facility Administrator (FA) Kathryn Nevin and explained the purpose of the visit.

During the visit, LPA toured the facility including resident rooms, interviewed staff and reviewed resident files.
LPA reviewed admission agreements, housekeeping checklists, and maintenance logs. It was learned that Resident 1 (R1) resides in the Independent Living section of the facility. Therefore, is not under Title 22 Regulations and is not licensed by Community Care Licensing. The above allegations are unfounded because the evidence shows it could not have happened, is false, or is without a reasonable basis.

An exit interview was conducted, and a copy of this report was provided to the facility.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Arielle Pascua
LICENSING EVALUATOR NAME: Sulma Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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