342700301-9-4-2025-27-AS-SRIN-DLN27U-20250918170919

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700301
Report Date: 09/04/2025
Date Signed: 09/04/2025 02:55:37 PM

Unsubstantiated

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
09/02/2025 and conducted by Evaluator Kimberly Viarella

COMPLAINT CONTROL NUMBER: 27-AS-20250902093942

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: 54	DATE:	09/04/2025
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Kathryn Nevin		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Resident felt pressured to sign a payment plan.

INVESTIGATION FINDINGS:

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On 09/04/25, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to open an investigation into the above allegation. LPA identified herself upon arrival, stated the purpose of the visit, and asked to meet with the Designated Facility Administrator/Executive Director (ED). LPA met with ED Kathryn Nevin and a brief interviewed followed.

Documents requested:
Admission Agreement for resident (R1) signed and dated 08/27/22
Eviction notice for R1 dated 08/28/25
Payment Agreement signed by R1 dated 04/09/25

Regarding the allegation: Resident felt pressured to sign a payment plan.

Over the course of 11 months, from 10/01/24 - 08/01/25, the R1 incurred charges that

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025

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-20250902093942

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: 09/04/2025

NARRATIVE

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amounted to $29,345.00. As of, 08/04/25, R1 paid $19,601.98 of that amount but still owed $9,743.02.

The Designated Facility Administrator/Executive Director (ED) Katherine Nevin, met with R1 in early April of 2025.

LPA was provided a copy of an agreement signed by R1 which stated that R1 would pay an additional $300.00 a month on top of the monthly charge of $2695.00 in order to bring R1's account up to date. R1 also signed an agreement with payee service , Helping Hearts, on 04/04/25 which went into effect on 05/01/25. The agreement with Helping Hearts stated that they would pay $2,117.00 and R1 was responsible for paying the remaining $878.00.

LPA interviewed R1 who stated that they knew they were behind in their payments and was afraid that they were going to be evicted so they signed the payment plan even though they knew they were not going to be able to pay the extra $300 dollars a month on top of their monthly fee of $2,595.00. This LPA learned in a conversation with the business office manager that when the facility asked R1 to contract with a payee service, the facility waived late fees which were in excess of $1,000.00.

LPA interviewed the 3 individuals present at the payment plan meeting: The ED, the Business Office Manager and the Regional Director (RM). R1 stated that they felt pressured because they were asked to sign a payment plan. The RM was surprised to learn that R1 felt pressured. They went on to state that oftentimes residents are hesitant to sign payee agreements but that R1 did so willingly.

R1 also stated that the ED had a conversation with R1 where they requested that R1 increase their payment from $300 to $400 because they were not keeping up with their payments. Another written agreement was not drafted because R1 continued to pay less than the monthly base charge for services.

During a meeting conducted today with R1 and the ED, the ED stated that they would assist R1 in finding a residence within their budget and also stated that they would connect R1 with a care coordinator to assist as well. R1 stated that they have begun to explore their options and mentioned a facility they had previous experience with. R1 also agreed to have a care conference which would include other parties who have assisted R1 with their financial responsibilities in the past.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20250902093942

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: 09/04/2025

NARRATIVE

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Regarding the allegation: Resident felt pressured to sign a payment plan.

R1 knew they owed over $9,000.00 in fees. The facility followed their protocol for when a resident falls behind in their payments; a payee organization is offered to assist with consistent payments and a payment plan agreement is suggested to assist in bringing accounts up to date.

Based on interviews and information that was gathered during this investigation, the standard for the preponderance of evidence to support the above allegation was not met. As a result, this LPA has determined that the above allegation to be UNSUBSTANTIATED.

A complaint allegation 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.
There were no deficiencies observed or cited at this time.

A copy of this report was provided along with a copy of the appeal rights and an exit interview was conducted with Nevin.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025

LIC9099 (FAS) - (06/04)

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