342700301-11-27-2023-27-AS-LRIS-CYAVXM-20231207154945

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700301
Report Date: 11/27/2023
Date Signed: 11/27/2023 04:36:50 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
10/17/2023 and conducted by Evaluator Vincent Moleski

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20231017104548

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: 62	DATE:	11/27/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Joe Dunham		TIME COMPLETED:	04:40 PM

ALLEGATION(S):

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Staff are not ordering resident's medication in a timely manner
Staff do not wear gloves when preparing foods
Residents are not provided adequate food service
Staff mismanaged resident's narcotic medication

INVESTIGATION FINDINGS:

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

This investigation consisted of interviews, observation, and record review.

LPA Moleski interviewed 13 staff members, including four kitchen staff (S3, S4, S11, S12) four caregivers (S5, S6, S14, S15), and four medication technicians (S7, S8, S9, S10). LPA Moleski interviewed 10 residents R1-R10.

LPA Moleski reviewed six residents’ (R1-R5, R9) medication administration records (MARs) for a period of at least three months each. LPA Moleski observed instances where medications were not given to residents R1, R2, and R5 due to running out of medications. According to S7, family members and/or residents ordered these medications, rather than medication technicians. [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: 11/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023

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-20231017104548

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: 11/27/2023

NARRATIVE

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R1, R2, and R5, confirmed that they or their family members order their medications. R9 said that R9 had run out of a medication. LPA Moleski reviewed eight months’ worth of MARs for R9 and did not observe that R9 had run out of this medication at any point since starting it, according to the MARs. During interviews, all four medication technicians (S7, S8, S9, S10) said there were no issues with staff ordering medications.

During a visit on 11/14/23, LPA Moleski observed staff count out all narcotic medications. LPA Moleski observed an accurate count and did not observe any irregularities. During interviews, all four medication technicians (S7, S8, S9, S10) said there were no issues with the narcotic count that were not otherwise accounted for.

During a visit on 11/27/23, LPA Moleski observed portions of lunchtime and dinnertime meal preparation. LPA Moleski observed staff taking appropriate hygienic measures, including glove use. During interviews, all four kitchen staff (S3, S4, S11, S12) described proper hygiene procedures. During interviews, residents did not voice concerns regarding hygienic procedures.

LPA Moleski observed postings in the kitchen containing special dietary information and documentation of doctors’ orders for special dietary restrictions. During interviews, no staff members were aware of issues with regard to special dietary orders. During interviews, one resident (R10) said that R10’s dietary orders were not being followed. LPA Moleski observed R10’s correct dietary information posted conspicuously in the kitchen.

The department has determined the following as it relates to the allegations that staff are not ordering resident's medication in a timely manner, staff do not wear gloves when preparing foods, residents are not provided adequate food service, and that staff mismanaged resident's narcotic medication:

Based on interviews, observations, and record review, the above allegations are UNSUBSTANTIATED, which means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations 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: 11/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023

LIC9099 (FAS) - (06/04)

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