342700301-3-25-2021-27-AS-KHOS-BZNJGU-20210401070254

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700301
Report Date: 03/25/2021
Date Signed: 03/25/2021 02:42:45 PM

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
12/18/2020 and conducted by Evaluator Danyle Wolter

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20201218132813

FACILITY NAME:	COUNTRY CLUB MANOR		FACILITY NUMBER:	342700301
ADMINISTRATOR:	CISCOE, MARIA		FACILITY TYPE:	740
ADDRESS:	2100 BUTANO DRIVE		TELEPHONE:	(916) 481-9240
CITY:	SACRAMENTO	STATE:	ZIP CODE:	95825
CAPACITY:	112	CENSUS: 45	DATE:	03/25/2021
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Maria Ciscoe, administrator		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Facility is withholding Personal Protective Equipment from staff
Facility is requiring Covid-19 Symptomatic staff to return to work.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Wolter contacted the facility via telephone on 03/25/2021 due to COVID-19 and precautionary measures to deliver complaint findings for the allegations listed above. LPA spoke to administrator Maria Ciscoe and explained the purpose of the call.

Throughout the course of the investigation the department conducted interviews and reviewed documentation relevant to the allegations: facility is withholding personal protective equipment (PPE) from staff and facility is requiring COVID-19 symptomatic staff to return to work.

Report continued on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Danyle Wolter	TELEPHONE: (916) 708-5307
LICENSING EVALUATOR SIGNATURE:	DATE: 03/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2021

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-20201218132813

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: 03/25/2021

NARRATIVE

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Documentation revealed that facility ordered PPE supplies and also picked up PPE supplies from the PPE drive held by the department. In interviews with staff the department was told that surgical masks were provided but N95 masks were not, staff interviews conducted also revealed conflicting information if symptomatic staff was required to return to work.

Due to the information above the departments finds the allegations to be UNSUBSTANTIATED, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted vie telephone. A copy of the report was emailed to administrator, administrator to return a signed copy of the report either by email, fax, or USPS. A signed copy should be retained for facility records as well.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Danyle Wolter	TELEPHONE: (916) 708-5307
LICENSING EVALUATOR SIGNATURE:	DATE: 03/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2021

LIC9099 (FAS) - (06/04)

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