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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700301
Report Date: 08/02/2024
Date Signed: 08/05/2024 05:11:02 PM


Document Has Been Signed on 08/05/2024 05:11 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 08/05/2024 11:06 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

NARRATIVE
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 Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced case management visit to this facility on 08/05/24 to amend a section of the LIC 809 D page regarding the evidence described in the report for type A deficiency cited on 08/02/24. The LPA identified herself upon arrival, stated the purpose of the visit, and asked to speak with the Designated Facility Administrator/Executive Director, Josef Dunham. A brief interview followed.

On 07/24/24, R2 stabbed R1 in the face with a fork during dinner. Staff, (S1) observed the incident and separated the two residents. S1 left R1 at the table and moved R2 across the room to another table. When S1 returned to check on R1, S1 asked if R1 was okay and R1 replied, "Why wouldn't I be?" S1 explained that they had just been stabbed in the face with a fork. According to S1, R1 replied, "I don't remember that." S1 notified the MedTechs and the Resident Services Coordinator. LPA met with R1 during today's visit and there were no visible marks on R1's face at the present time.

LPA learned through interviews that the MedTech on duty (S2) completed an incident report for R2 and contacted R2's responsible party and primary care physician. S2 should have also completed an incident report for R1 and notified their responsible party and primary care physician as well. However, according to the California Code of regulations Reporting Requirements, 87211(a)(1)(D) "(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in... (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (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."

The incident report for R1 was completed on 07/25/24 by S2 as requested by the Resident Care
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 08/02/2024
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Coordinator. The report stated that there was a small mark under the resident's eye and that R1 was not bleeding or complaining. The resident was not sent out for further evaluation.

The responsible party and primary care physician for R1 were not notified although the boxes indicating that they were, had been checked off. Through interviews with S1, this LPA observed that
additional training was needed in the area of reporting to ensure mistakes in documentation and communication do not happen in the future. This deficiency was cited on the LIC 809D page.

LPA requested the following documents for both residents:
LIC 602s, Physicians Reports
LIC 603s Pre-appraisals
LIC 625s Care Plans
LIC 624s Incident Reports
  • LPA found that the last LIC 602 for R1 was completed on 12/20/23 and the annual exam was not due at this time.

  • LPA found that the last LIC 602 for R2 was completed on 9/21/22 and was overdue. This deficiency was cited on the LIC 809 D page. The Resident Care Coordinator have been in communication with R2's responsible party and requested assistance in scheduling an annual exam for R2.

During today's walkthrough of the facility, this LPA observed 2 med techs, 4 caregivers, 2 housekeepers and 1 maintenance worker assisting a resident with a TV installation. LPA observed lunch being served in the dining room. In order to prevent any other altercations between R1 and R2 in the dining room, the table at which they sat was relocated and each resident was redirected to another table with a different dining companion. This LPA met both R1 and R2 and each displayed a calm and friendly affect.

According to the California Code of Regulations, Title 22, all deficiencies were cited on the LIC 809D pages and a copy of this report along with Appeal Rights, was provided. Exit interview.

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

DATE: 08/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 08/02/2024 02:10 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 08/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/16/2024
Section Cited
CCR
87207

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87207 False Claims
No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility.
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Administrator stated that additional training on incident reporting will be completed and an incident report checklist will be created to ensure that all steps are completed in the appropriate order and time frame. A copy of the participant signature sheet and the checklist will be emailed to licensing at:
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The facility did not comply with the above requirement as evidenced by the fact that their documentation (LIC 624) indicated that the responsible party and the primary care physician of R1 had been notified and they had not. This posed a posed a potential threat to the Health, Safety, and Personal Rights of residents in care.
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kimberly.viarella@dss.ca.gov.

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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: 08/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 08/05/2024 05:12 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 08/05/2024 11:08 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 08/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/03/2024
Section Cited
CCR
87463(c)

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87463(c) Reappraisals
(c) The licensee shall arrange a meeting with the resident, the resident’s representative...when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.

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The Administrator will ensure that the Primary Care Physician's office as well as the responible party will be contacted by the close of business to schedule and annual examiniation for R2. A copy of the FAX transmittal sheet and /or emails to these parties will be submitted to Licensing at:
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The facility did not comply with the above requirement as evidenced by a records review showing that R2's LIC 602 was dated 09/21/22. R2 had a listed diagnosis of dementia in her medical reports and a reappraisal should have been done by 09/21/23.
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Kimberly.viarella@dss.ca.gov.

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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: 08/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4