342700301-7-12-2023-27-AS-CACL-CTXST7-20230721140905

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700301
Report Date: 07/12/2023
Date Signed: 07/12/2023 02:35:10 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
05/03/2023 and conducted by Evaluator Ruth Wallace

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20230503160533

FACILITY NAME:	COUNTRY CLUB MANOR		FACILITY NUMBER:	342700301
ADMINISTRATOR:	VENEGAS, MARICAR		FACILITY TYPE:	740
ADDRESS:	2100 BUTANO DRIVE		TELEPHONE:	(916) 481-9240
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95825
CAPACITY:	112	CENSUS: 58	DATE:	07/12/2023
		UNANNOUNCED	TIME BEGAN:	02:20 PM
MET WITH:	Mary Lindgren - Business Office Manager		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Facility is in disrepair
Facility does not provide a safe environment for residents
Facility allowing individuals without fingerprint clearance at facility
Facility staff is stealing money

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced facility visit to complete and delivery findings for a complaint investigation received on 5/3/23. LPA met business officer manager and discussed the conclusion for complaint and the findings. Business office manager notified licensee of visit.

Based on LPA observations of facility, kitchen, common areas, resident rooms, maintenance receipts, and interviews of staff and residents; the facility is not in disrepair. The licensee has owned property a couple of years and is completing repairs as needed. The company has a maintenance crew that is available for all 12 facilities and licensee is in the process of hiring a new maintenance crew for country club manor. LPA tour of facility, maintenance receipts, and interviews, the allegation of facility is in disrepair was not observed by LPA.

Based on LPA observations of facility, resident rooms, and interviews of staff and residents: LPA did not find facility to be a safe environment for the residents.2

Continued on 9099-C Page

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth Wallace	TELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2023

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-20230503160533

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: 07/12/2023

NARRATIVE

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Continued from 9099 - Page 2

Based on LPA observations, interviews of staff and residents, tour of facility, sign in/out logs, and locked doors for night hours until early morning. The homeless or other citizens do use the bus bench which is located on sidewalk out in front of country club manor building. The allegation that facility does not provide a safe environment for residents is UNSUBSTANTIATED.

Based on LPA observations of facility, record reviews, and staff and resident interviews there has been no direct knowledge of facility staff stealing money.

As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED.
Due to the above noted information, although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, and therefore the allegations are unsubstantiated.

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit.

An exit interview was conducted, a copy of the 9099 and 9099-C, LIC 811 (Confidential Names), and appeal rights were provided to the facility.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth Wallace	TELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2023

LIC9099 (FAS) - (06/04)

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