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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700301
Report Date: 01/14/2021
Date Signed: 01/14/2021 02:14:48 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
04/24/2020 and conducted by Evaluator Jasmine McCrory
COMPLAINT CONTROL NUMBER: 27-AS-20200424122123
FACILITY NAME:COUNTRY CLUB MANORFACILITY NUMBER:
342700301
ADMINISTRATOR:CISCOE, MARIAFACILITY TYPE:
740
ADDRESS:2100 BUTANO DRIVETELEPHONE:
(916) 481-9240
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:112CENSUS: DATE:
01/14/2021
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Maria Cicscoe, AdministratorTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Allegation: Staff mishandling resident’s medication.
INVESTIGATION FINDINGS:
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On 01/14/2021 at 10:58 AM Licensing Program Analyst (LPA) McCrory contacted the facility via telephone to deliver findings for the above allegation. Findings are delivered via telephone due to COVID-19 precautionary measures. LPA explained the purpose of the call to Administrator (Admin) Maria Ciscoe.
During the investigation, LPA interviewed the facility staff and relevant parties, and obtained documentation pertinent to the investigation.

Allegation: Staff mishandling resident’s medication.

The allegation indicates that on the evening of 04/21/2020, a resident (R1) was unable to get a medication as needed.
Interviews revealed that R1 who was having difficulty breathing and asked a Med Tech (S1) to get R1 a breathing treatment (nebulizer). S1 came back with R1’s inhaler. When R1 informed S1 that she brought the incorrect medication and asked where her treatment was, S1 informed her that the facility did not have the medication on hand. (continued)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jasmine McCroryTELEPHONE: (916) 214-5020
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2021
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 5
Control Number 27-AS-20200424122123
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: 01/14/2021
NARRATIVE
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LPA was informed that the facility was out of R1’s medication and R1’s family came to the facility and delivered a like-product (same medication, but not the correct dosage). LPA learned that S1 administered this medication even though it was not prescribed to R1 and it was the wrong dose.

Administrator Maria Ciscoe stated that she was aware of the situation and confirmed the details of the allegation. She stated that the facility had R1’s nebulizer solution on hand but that S1 did not find R1’s medication in the med room because she was not looking in the correct location. Maria stated that once she learned what happened, she removed S1 from Med Tech duties and is in the process of retraining all the facility Med Techs.

Based on interviews with residents, the preponderance of evidence standards has been met, and therefore the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22 Division 6, Chapter 9, deficiencies are being cited on the attached 9099D during this visit.

A previous licensing report was issued on 12/30/2020 giving notice of the same violation. Because you have been cited for repeating the same violation within 12 months a civil penalty shall be assessed on attached LIC421FC.
The following deficiency is being cited on the attached LIC 9099-D:
§1569.69 Employees assisting residents with self-administration of medication; training requirements
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (1) In facilities licensed to provide care for 16 or more persons, the employee shall complete 24 hours of initial training. This training shall consist of 16 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 8 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first four weeks of employment.

An exit interview was conducted with Administrator via telephone and a copy of this report and Appeal Rights will be provided to the facility via email. This facility shall sign and return a copy of the report to Community Care Licensing by mail and print a copy to be retained by the facility.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jasmine McCroryTELEPHONE: (916) 214-5020
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20200424122123
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/14/2021
Section Cited
HSC
1569.69(a)(1)
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1569.69 (a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements (...)
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Licensee agrees to create an onboarding process for new staff that includes a schedule of medication training to ensure all requirements are met prior to staff handling medications, the same training...
(continued below).
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This training shall consist of 16 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications (...).
This is not evidenced based on records reviewed, the facility did not ensure qualified assistance was given to Residents. this poses a potential health and safety risk to residents in care
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should be used for any staff who will handle residents medications. New hire training and recertifcation. Copy of plan to be sent to CCL by 02/01/2021.
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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: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jasmine McCroryTELEPHONE: (916) 214-5020
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
04/24/2020 and conducted by Evaluator Jasmine McCrory
COMPLAINT CONTROL NUMBER: 27-AS-20200424122123

FACILITY NAME:COUNTRY CLUB MANORFACILITY NUMBER:
342700301
ADMINISTRATOR:CISCOE, MARIAFACILITY TYPE:
740
ADDRESS:2100 BUTANO DRIVETELEPHONE:
(916) 481-9240
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:112CENSUS: DATE:
01/14/2021
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Maria Cicscoe, AdministratorTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Staff did not refill resident’s medication prescription in a timely manner.
Staff did not arrange transportation for resident following doctor’s visit.
INVESTIGATION FINDINGS:
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On 01/14/2021 at 11:08AM Licensing Program Analyst (LPA) McCrory contacted the facility via telephone to deliver findings for the above allegations. Findings are delivered via telephone due to COVID-19 precautionary measures. LPA explained the purpose of the call to Administrator (Admin) Maria Ciscoe.
During the investigation, LPA interviewed the facility staff and relevant parties, and obtained documentation pertinent to the investigation.

Allegation: Staff did not refill resident’s medication prescription in a timely manner.

The allegation indicates that R1 was told the facility was out of R1’s nebulizing solutions for her breathing treatment and that a relevant party was informed that the facility had ordered it three days prior and were still waiting on it to be filled. (continued)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jasmine McCroryTELEPHONE: (916) 214-5020
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20200424122123
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: 01/14/2021
NARRATIVE
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Interviews revealed that the facility had the medication in stock at the time that R1 requested it but that the Med Tech did not know where it was in the med room.

Allegation: Staff did not arrange transportation for resident following doctor’s visit.

The allegation indicates that the facility failed to drive R1 to a doctor’s appointment in February 2020.
During interviews, LPA was unable to discern from the resident or relevant parties when the missed appointment for R1 occurred. Staff interviews indicated that R1 was only receiving transportation from the facility driver for her lab work visits which occurred earlier in the day when the driver S2 worked from 8am to 12pm. Staff stated that R1 would get rides to her doctor’s appointments from a family member and then later through a services set up through her medical provider. S2 stated that S2 does not recall being unavailable to take R1 to get R1’s lab work done during February.

Based on interviews, observations, and record review, the LPA finds these allegations 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 with the Administrator via telephone and a copy of this report will be provided to the facility via email. This facility shall sign and return a copy of this report to Community Care Licensing via mail and print a copy to be retained by the facility.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jasmine McCroryTELEPHONE: (916) 214-5020
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5