342700301-11-17-2023-27-AS-KHOS-CZRRJE-20240123120349

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700301
Report Date: 11/17/2023
Date Signed: 11/17/2023 04:22:51 PM

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
11/15/2023 and conducted by Evaluator Victoria Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20231115162214

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:	11/17/2023
		UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	Sarah Blane McClain		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff do not properly sanitize the facility grounds
Staff do not properly maintain a resident's room
Staff do not keep a resident's room free from pests
Staff are not addressing a resident's change in medical condition

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct an investigation of the above mentioned allegations on 11/17/23 at 2:45pm. LPA met with Sarah Blane McClain, Resident Care Coordinator and stated the purpose of the visit. Sarah Blane McClain, Resident Care Coordinator contacted the Administrator regarding todays visit. LPA toured the facility which included the kitchen, a random amount of resident rooms and bathrooms, and conducted interviews of residents and staff during this visit.

Regarding allegation, Staff do not properly sanitize the facility grounds, LPA observed housekeeping and maintenance performing duties during this visit. LPA obtained information that the carpet throughout the facility has been recently cleaned on 11/6/23 by First Class Carpet Cleaning. LPA did not observe a foul odor in the facility during this visit.

Unfounded

Estimated Days of Completion: 60

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2023

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-20231115162214

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: 11/17/2023

NARRATIVE

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Regarding allegation, Staff do not properly maintain a resident's room, LPA observed a random amount of rooms and conducted interviews of residents and staff who confirmed that the residents have a laundry scheduled day and are asked if they want bedding to be cleaned and there is additional laundry conducted when there is incontinence issues. LPA observed a housekeeping schedule which indicates which rooms and which days are assigned for staff to clean on a weekly basis which includes the bathrooms, windows, and common areas. LPA observed a laundry schedule that indicates a designated staff who does laundry for 8 hours Monday through Friday and on the weekends the PM shift staff are assigned to do the laundry.

Regarding allegation, Staff do not keep a resident's room free from pests, LPA observed a random amount of rooms and did not observe evidence and/or droppings of roaches, and bedbugs, nor ant trails. Residents and staff interviewed confirmed that residents do not have bugs in their rooms. Aantex Pest Control conducts treatment and pest activity inspection of the kitchen, outside foundation, spot and crevasse and selected trees. LPA observed that the most recent pest control fumigation was conducted on 10/31/23.

Regarding allegation, Staff are not addressing a resident's change in medical condition, LPA obtained information through interviews that resident #1 had a rash that began on 11/8/23 which was being treated by a physician. The rash was not due to bedbugs bites.

Based on interviews and observation, the allegation(s) are deemed UNFOUNDED.

The allegation is UNFOUNDED, meaning that the allegation was false, could not have happened and/or was without a reasonable basis. This Department has therefore dismissed the complaint.

Per California Code of Regulations, no deficiencies were observed or cited. Exit interview held, and a copy provided.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2023

LIC9099 (FAS) - (06/04)

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