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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700301
Report Date: 12/06/2024
Date Signed: 12/06/2024 04:30:27 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
08/05/2024 and conducted by Evaluator Kimberly Viarella
COMPLAINT CONTROL NUMBER: 27-AS-20240805120016
FACILITY NAME:COUNTRY CLUB MANORFACILITY NUMBER:
342700301
ADMINISTRATOR:DUNHAM, JOSEFFACILITY TYPE:
740
ADDRESS:2100 BUTANO DRIVETELEPHONE:
(916) 481-9240
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:112CENSUS: 63DATE:
12/06/2024
UNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Joe DunhamTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Facility did not notify the responsible party of an incident.
Due to a lack of supervision, resident was assaulted by another resident multiple times while in care.
Facility did not put a plan in place to protect a resident from being physically attacked by another resident.
INVESTIGATION FINDINGS:
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On 12/06/24, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to deliver the findings for this complaint investigation into the above allegations. The LPA identified herself upon arrival, stated the purpose of her visit and asked to meet with the Executive Director (ED). LPA met with ED Josef Dunham and a brief interview followed.

Regarding: Facility did not notify the responsible party of an incident.
* This allegation was previously addressed as part of a case management on 08/02/24 and the faciity was cited under California Code or Regulations, CCR 87207.
An incident occurred in the dining room on 07/24/24 during dinner: a resident (R1) was stabbed in the face with a fork by another resident in care (R2). Community Care Licensing (CCL) and the Ombudsman's office were notified of the incident by the facility, however, this LPA learned through interviews with S2, S3, and S5, that the responsible party for R1 was not. R1's responsible party was notified by the Ombudsman (O1) when O1 called to follow up on the incident report that was received. The standard for the preponderance of evidence was met and the department found the above allegation SUBSTANTIATED. According to the California Code of Regulations, Title 22, this deficiency was cited on the LIC 9099D page.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 27-AS-20240805120016
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: 12/06/2024
NARRATIVE
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Regarding: Due to a lack of supervision, resident was assaulted by another resident multiple times while in care.

R1 was assaulted by R2 on 07/24/24 in the dining room with a fork. The two sat together at a specific table and were regular dining companions.  In order to prevent future incidents, the ED removed their dining table and had staff redirect the two residents to sit with different dining companions.

The second assault occurred at 7:30 AM on 08/04/2024. The following was learned through interviews conducted by this LPA and the Ombudsman (O1). This second assault was witnessed by kitchen staff (K1). K1 stated that a dietary aid (D1) saw R2 and R1 arguing at a table. D1 said they moved R2 to another table and as R2 did so, R2 hit R3 in the head.  R3 went to the lobby to tell someone in charge and another member of the kitchen staff (K2) took R2 to a table in the back of the dining room.

The responsible party (RP) for R1 was notified of this incident at approximately 9:39 AM by S7. The RP was told R1 was moved to the Sun Room and that they were doing fine. The RP said that they were on their way.  RP and their spouse arrived at approximately 10:30ish and found that R1 was in the Sun Room with 5 other residents, one of them being their attacker.  There were no staff present in the room.

According to an interview with O1 on 08/07/24, when O1 spoke to the ED regarding the monitoring of R2, the ED stated that no one was assigned one-on­one to watch R2 despite his assurance R2 would be monitored. When asked why no staff was in the dining room where and when the assaults occurred, the ED stated they were outside the room getting residents ready to go into the dining room.

When this LPA interviewed the ED on 08/05/24 as part of a case management regarding the first assault, the ED stated that they would increase monitoring of R1 and R2 and keep them separated.  For meals, he said that most residents were escorted to the dining room. Because care staff were assisting residents from their rooms to the dining room, the residents in the dining room were left unsupervised resulting in multiple assaults of R1 and R3. The standard for the preponderance of evidence has been met and the department finds the above allegation to be SUBSTANTIATED.  According to the California Code of Regulations, Title 22, this deficiency was cited on the LIC 9099D page.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 27-AS-20240805120016
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: 12/06/2024
NARRATIVE
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Regarding : Facility did not put a plan in place to protect a resident from being physically attacked by another resident.

During the case management visit that took place on 08/02/24, regarding the first assault that occurred on 07/24/24, the ED's plan was to separate R1 and R2 by ensuring that they were not seated at the same table during meals and to increase monitoring. The ED removed the table entirely and used its absence as a justification for seating the two residents at separate locations with new dining companions.  When this LPA visited the facility on 08/05/24, kitchen staff had replaced the table to the original floor plan. The ED immediately removed the table.

On 08/07/24, R1 was assaulted by R2 again in the dining room. This LPA learned through a review of records that R2 had 4 "Stop and Watch" communications on file for the following dates: 12/08/23, 12/09/23, 01/21/24, and 02/19/24. They described various incidents and/or attempts of aggressive behavior by R2 towards other residents.  Based on the documentation reviewed, R2 required additional monitoring in order to maintain the safety of the residents in care.  After the assault on 7/24/24, the ED stated that the facility would increase monitoring.  If there had been a monitoring plan put in place, then the assaults on R1 and R3 would not have occurred, however the dining room was left unattended by care staff and 2 residents were struck by R2. 

The standard for the preponderance of evidence has been met and the department finds the above allegation to be SUBSTANTIATED.   According to the California Code of Regulations, Title 22, this deficiency was cited on the LIC 9099D page.

No other deficiencies were observed or cited during today's visit. A copy of this report along with APPEAL RIGHTS were provided.

Exit interview.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 27-AS-20240805120016
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: 12/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/06/2025
Section Cited
CCR
87211(a)(1)(D)
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Reporting Requirements
(a) Each licensee shall furnish...the following: (1) A written report to the licensing agency and to the person responsible for the resident...(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.
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A training on incident reports and reporting requirements was conducted by the clinical regional specialist for Allen Flores and submitted to Licensing as part of the POC for the deficiency cited during the case management on 08/02/24, which was during the same time period as this complaint. This POC has been cleared.
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The above requirement was not met as evidenced by:
Based on interviews with S2, S3, and S5, the responsible party for R1 was not notified of the incident with R2. This posed a potential threat to the health, safety, and personal rights of the residents in care.
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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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Citations on this Visit Report are Under Appeal!

Control Number 27-AS-20240805120016
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: 12/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
12/07/2024
Section Cited
CCR
87468.1(a)(2)
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Personal Rights of Residents in All Facilities - (a) Residents...shall have following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
The above requirement was not met as evidenced by:
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The ED stated that he will sign an attestation stating that in the future, if a resident is being targeted/assaulted by another resident, increased monitoring will be initiated up to and including 1-1 supervision if necessary to ensure resident safety.
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Based on a review of records, as well as through interviews with K1, K2, and R3, R1 was attacked on 07/24/24, 08/04/24, and R3 was struck on 08/04/24 as well. This posed an immediate risk to the health, safety, and personal rights of the residents in care.
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Under Appeal
Type A
12/07/2024
Section Cited
HSC
1569.2(c)
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1569.2 Definitions - (c) “Care and supervision” means the facility assumes responsibility for...ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered.
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The ED stated that an attestation will be signed by all care and dining staff stating that all staff understand that residents must be monitored while in the dining room at all times. This document will be submitted to CCL at kimberly.viarella@dss.ca.gov by 12/07/24.
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The above requirement was not met as evidenced by:
Based on a review of records, R2 had a history of aggressive behavior. Based on interviews, residents in the dining room were left unsupervised. This posed an immediate risk to the health, safety and personal rights of residents in care.
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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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6
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
08/05/2024 and conducted by Evaluator Kimberly Viarella
COMPLAINT CONTROL NUMBER: 27-AS-20240805120016

FACILITY NAME:COUNTRY CLUB MANORFACILITY NUMBER:
342700301
ADMINISTRATOR:DUNHAM, JOSEFFACILITY TYPE:
740
ADDRESS:2100 BUTANO DRIVETELEPHONE:
(916) 481-9240
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:112CENSUS: DATE:
12/06/2024
UNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Joe DunhamTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Staff are not trained to care for residents with dementia.
INVESTIGATION FINDINGS:
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On 12/06/24, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to deliver the findings for this complaint investigation into the above allegations. The LPA identified herself upon arrival, stated the purpose of their visit and asked to meet with the Executive Director (ED). LPA met with ED Josef Dunham and a brief interview followed.

Regarding: Staff are not trained to care for residents with dementia.
On 10/08/24, Licensing Program Manager Stephen Richardson and this LPA conducted a review of 6 staff files. All 6 files contained dementia care training. The standard for the preponderance of evidence has not been met and the Department finds the above allegation UNSUBSTANTIATED. A finding of unsubstantiated 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.

According to the California Code of Regulations, no deficiencies were observed or cited during this visit. A copy of this report was provided and an exit interview was conducted with Joe Dunham.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6