342700301-6-26-2024-27-AS-LKIG-D7NW5X-20240730165949

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700301
Report Date: 06/25/2024
Date Signed: 06/26/2024 03:05:25 PM

Substantiated

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
05/22/2024 and conducted by Evaluator Charlie Yang

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20240522123224

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: 67	DATE:	06/25/2024
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Sarah Nichols and Josef Dunham		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff are not providing residents with a comfortable environment

INVESTIGATION FINDINGS:

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Unannounced complaint visit made out to this facility on 06/25/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the Resident Services Director, Sarah Nichols, who was briefly interviewed at this time.
This LPA requested that she go ahead and inform the facility designated Administrator Josef Dunham to inform him that CCL was present at this time. The facility designated Administrator, Josef Dunham, arrived later to this facility while this LPA was conducting this complaint visit.
Current census was 67 residents.
The purpose of this visit was to deliver the findings of this investigation to this facility and it's representative at this time.
Based on interviews conducted during this complaint investigation, it was learned that there were two residents, R1 and R2, who resided as roommates in this facility. It was learned that one of the roommates was unable to use the pull chord effectively since this particular resident had impairment issues with their vision. It was learned that there was only one pull chord present in the room and it was centrally located.

Substantiated

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: 06/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2024

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-20240522123224

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: 06/25/2024

NARRATIVE

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It was observed that there were no other pull chords present in the restroom or other parts of the resident bedrooms at this time.
It was learned that this resident, R1, who was unable to properly see the singular pull chord would call out when assistance was needed instead of attempting to use the emergency pull chord system. The roommate, R2, would also join in on this call for help and call out loudly for facility care staff.
It was learned that this behavior took place about 4 to 5 times during normal business hours and another 2-3 times during after hours for a total of up to 8 times in a 24 hour time period.
These outbursts could last from anywhere from a minute or two up to 5 minutes or more depending on how swift facility staff responded.
Based on interviews conducted, it was learned that this ongoing behavior by R1 and R2 made it very difficult for nearby residents to relax and stay in their rooms without feeling annoyed or agitated. The level, and consistency, of the outbursts from R1 and R2 interrupted their regular day to day activities and interfered when residents were trying to sleep at night as well. This made it difficult for residents to feel comfortable with this type of behavior taking place everyday and on a regular basis as well.

As a result of this investigation, this LPA found the allegation to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met.

The following deficiencies were observed and cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes.

Appeal rights were printed and a copy was left with the facility designated Administrator at this time.

Exit Interview

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2024

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20240522123224

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/25/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/26/2024 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This facility was found to be deficient as	1 2 3 4 5 6 7	The facility designated Administrator stated that a plan will be constructed to deal with the ongoing outbursts of the (2) residents. This plan will involve the roles and responsibilities of this facility, the involvement of the responsible parties, and input from licensed medical professionals in assessment
	8 9 10 11 12 13 14	evidenced by the presence of facility residents who infringed on the personal rights of nearby residents on a daily basis making them uncomfortable in their living spaces and environment. This posed an immediate threat to the Health, Safety, and Personal Rights of residents in care.	8 9 10 11 12 13 14	and possible relocation if warranted at this time. A statement of correction, along with this updated plan will be completed and submitted into CCL by the due date.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2024

LIC9099 (FAS) - (06/04)

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