342700301-12-11-2023-27-AS-SRIN-CYX2KT-20231227162827

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700301
Report Date: 12/11/2023
Date Signed: 12/11/2023 09:23:45 AM

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
11/06/2023 and conducted by Evaluator Vincent Moleski

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20231106124359

FACILITY NAME:	COUNTRY CLUB MANOR		FACILITY NUMBER:	342700301
ADMINISTRATOR:	DUNHAM, JOSEF		FACILITY TYPE:	740
ADDRESS:	2100 BUTANO DRIVE		TELEPHONE:	(916) 481-9240
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95825
CAPACITY:	112	CENSUS: 61	DATE:	12/11/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Joe Dunham		TIME COMPLETED:	09:30 AM

ALLEGATION(S):

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Staff did not meet resident's hygiene needs.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with facility administrator Joe Dunham and explained the purpose of the visit.

This investigation consisted of interviews and record review.

LPA Moleski interviewed five residents (R1, R2, R4, R6, and R9) and eight staff members (S1, S5, S6, S7, S8, S13, S14, and S15).

All staff members interviewed said that two-hour continence checks are performed. In interviews, S1, S5, S7, S13, and S14 had no concerns regarding continence care. S8 said residents sometimes refuse continence care. S15 said R6 sometimes refuses continence care. S6 said that R6 has been left in dirty garments and is not always changed when needed.

[continued on 9099-C]

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent Moleski	TELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:	DATE: 12/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023

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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Control Number 27-AS-20231106124359

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: 12/11/2023

NARRATIVE

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In interviews, R1, R2, R4, and R9 did not share concerns regarding continence care. R6 said R6 is “never” left in dirty garments, and said that staff clean her frequently.

LPA Moleski reviewed R6’s file. According to R6’s LIC 601, R6 is self-responsible. According to R6’s LIC 602, dated 5/18/23, R6 uses pull-ups. According to the LIC 602, R6 does not have dementia.

LPA Moleski reviewed daily notes regarding R6 dating between March 2023 and October 2023. LPA Moleski observed a note written by S8 and dated 9/21/23 which describes an incident wherein S8 was passing out medications when R6 asked to be changed. S8 called for a caregiver to help R6, according to the note. R6 was “upset” because R6 could not get immediate assistance, but a caregiver did arrive and assisted R6, according to the note.

The department has determined the following as it relates to the allegation that staff did not meet a resident’s hygiene needs:

Based on interviews and record review, the above allegation is UNSUBSTANTIATED, which means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

No deficiencies were cited during this visit. An exit interview was held and a copy of this report was left with Dunham.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent Moleski	TELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:	DATE: 12/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023

LIC9099 (FAS) - (06/04)

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