342700301-3-19-2024-27-AS-KHOS-D3PH4V-20240325055233

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700301
Report Date: 03/14/2024
Date Signed: 03/19/2024 05:41:25 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
09/27/2023 and conducted by Evaluator Charlie Yang

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20230927083554

FACILITY NAME:	COUNTRY CLUB MANOR		FACILITY NUMBER:	342700301
ADMINISTRATOR:	FOZ, ROMERICO		FACILITY TYPE:	740
ADDRESS:	2100 BUTANO DRIVE		TELEPHONE:	(916) 481-9240
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95825
CAPACITY:	112	CENSUS: 66	DATE:	03/14/2024
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Sarah Nichols		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff mismanaged resident's medication

Staff refused to provide proper bedding for resident in care

Staff did not assist resident in a timely manner

INVESTIGATION FINDINGS:

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Unannounced complaint visit made out to this facility on 03/14 2024 by Licensing Program Analyst (LPA) Charlie Yang was met by the facility designated representative Sarah Nichols. A brief interview was conducted with the facility designated representative at this time.
This LPA requested that this facility representative go ahead and contact the facility designated Administrator, Josef Dunham, that CCL was present at this time. It was learned that the facility designated Administrator was unable to be present at this time for this complaint visit.
Current census was 66 residents.
The purpose of this complaint visit was to deliver the findings of this investigation to this facility and its representative at this time.
Based on a review of the facility medication administration records, and a copy of a recent medication audit conducted by a third party vendor, it was observed that this facility was following physician's orders when dispensing, documenting, and handling resident medications at this time.
The third party vendor audit reviewed 26 facility resident medications and observed that there weren't any

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024

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-20230927083554

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: 03/14/2024

NARRATIVE

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components that were out of compliance at the time of the review.
Based on a review of the facility personnel schedule and interviews conducted, it was learned that housekeeping staff were responsible for cleaning and maintaining the facility resident rooms on a weekly basis. It was learned that resident rooms were cleaned on a weekly basis, or as needed, if additional cleanings were necessary. This facility employed staff solely dedicated to housekeeping and staff dedicated solely for laundry services that were provided on a weekly basis as well.
Based on interviews conducted, it was learned that the housekeeping and laundry staff were efficient in their tasks and there weren't any concerns at this time.
Based on interviews conducted, it was learned that pull cords were installed in the resident rooms and restrooms. It was learned that the facility staff were expected to respond to alerts when the residents activated their pull cords. It was learned that a reasonable response time was to be within 5 minutes of pull cord activation while anything that went over the 5 minute mark was deemed to be unreasonable. It was learned that facility residents did not have any issues with the staff responding to pull cords and requests from the facility staff at this time. Facility staff were responding accordingly and within the reasonable amount of time.

As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegations finding of Unsubstantiated meant that although the allegations may have happened or were valid, there was not a preponderance of the evidence to prove that the alleged violations occurred.

There were no deficiencies observed or cited during this complaint visit.

Exit Interview

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024

LIC9099 (FAS) - (06/04)

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