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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700301
Report Date: 10/13/2023
Date Signed: 10/13/2023 03:36:38 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/06/2023 and conducted by Evaluator Tung Truong
COMPLAINT CONTROL NUMBER: 27-AS-20230906163745
FACILITY NAME:COUNTRY CLUB MANORFACILITY NUMBER:
342700301
ADMINISTRATOR:FOZ, ROMERICOFACILITY TYPE:
740
ADDRESS:2100 BUTANO DRIVETELEPHONE:
(916) 481-9240
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:112CENSUS: 57DATE:
10/13/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Josef Dunham, AdministratorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff are not adhering to resident's care plan.
Staff did not ensure that resident in care was provided their medication(s).
Staff retaliated against resident for filing a complaint.
INVESTIGATION FINDINGS:
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On 10/13/23, Licensing Program Analyst (LPA) Tung Truong arrived at the facility unannounced to conclude the investigation of the above allegations and to deliver the findings. LPA met with Administrator Josef Dunham and explained the purpose of the visit.

Throughout the course of the investigation, LPA conducted interviews and reviewed records. Based on LPA observations of facility, record reviews, and staff and resident interviews there has been no direct knowledge of facility staff not adhering to resident’s care plan. Residents who were interviewed did not express any concerns with care being provided. Regarding the allegation that staff did not ensure that resident in care was provided their medication(s), LPA reviewed resident's medication log and observed no irregularities. Based on resident interviews, residents stated that they do receive their medications.

Continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2023
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 3
Control Number 27-AS-20230906163745
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: COUNTRY CLUB MANOR
FACILITY NUMBER: 342700301
VISIT DATE: 10/13/2023
NARRATIVE
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Based on staff interviews, staff stated that all residents receive their medications timely and there have been no incidents in recent months. It was learned that LPA Johnson substantiated Staff mismanaging resident medication on 4/6/2023 by Complaint Control Number: 27-AS-20230224163937. It was learned that were no other incidents pertaining to medications since. Regarding the allegation that facility staff retaliated against resident for filing a complaint, there is not a preponderance of evidence to prove that it occurred.

As a result of the investigation, LPA finds the allegations above to be UNSUBSTANTIATED- A finding that the complaint is 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.

An exit interview was conducted, and a copy of the report was provided.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/06/2023 and conducted by Evaluator Tung Truong
COMPLAINT CONTROL NUMBER: 27-AS-20230906163745

FACILITY NAME:COUNTRY CLUB MANORFACILITY NUMBER:
342700301
ADMINISTRATOR:FOZ, ROMERICOFACILITY TYPE:
740
ADDRESS:2100 BUTANO DRIVETELEPHONE:
(916) 481-9240
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:112CENSUS: 57DATE:
10/13/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Josef Dunham, AdministratorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff administered the wrong medication to resident in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 10/13/23, Licensing Program Analyst (LPA) Tung Truong arrived at the facility unannounced to conclude the investigation of the above allegations and to deliver the findings. LPA met with Administrator Josef Dunham and explained the purpose of the visit.

Throughout the course of the investigation, LPA conducted interviews and reviewed records. Regarding the allegation that staff administered the wrong medication to resident in care, no supporting information was discovered. Facility administrator and staff stated that they have no knowledge of any medication errors.

As a result of this investigation, LPA finds the allegation above to be UNFOUNDED, meaning that the allegation was false, could not have happened and/or was without a reasonable basis.

An exit interview was conducted and a copy of the report was provided.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2023
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 3