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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700301
Report Date: 04/19/2021
Date Signed: 04/19/2021 01:46:09 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/24/2020 and conducted by Evaluator Danyle Wolter
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20201224152846
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: 47DATE:
04/19/2021
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Maria Ciscoe, administratorTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Facility denying access to phones.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Wolter contacted the facility by phone on 04/19/2021 to deliver complaint findings due to COVID-19 and precautionary measures, LPA spoke to administrator Maria Ciscoe and explained the purpose of the call.

Throughout the course of the investigation the department conducted interviews relevant to the allegation: facility denying access to phones. Interviews revealed that there is not a phone in a common area for residents to use, residents must request to use the phone with the receptionist. The department was told by R1 that they are not always allowed to use the phone when they’d like and are not allowed to use the phone unsupervised.

Due to this information the preponderance of evidence standard has been met, therefore the above allegation is determined to be SUBSTANTIATED. The deficiency is cited on the attached LIC 9099-D
Exit interview condcuted. Copy of report and appeal rights emailed to administrator, signed copy to be returned to the department. Facility should also retained a signed copy for records.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Danyle WolterTELEPHONE: (916) 708-5307
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2021
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 3
Control Number 27-AS-20201224152846
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: COUNTRY CLUB MANOR
FACILITY NUMBER: 342700301
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/19/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/03/2021
Section Cited
CCR
87468.1(a)(14)
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Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (14) To have reasonable access to telephones, to both make and receive confidential calls. The licensee may require reimbursement for long distance calls.
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Licensee to supply a phone for residents that can be used to make and receive confidential calls, either by putting a phone in the common area or purchasing a phone with handheld capabilities that residents can use away from the receptionist desk. Proof of correction due to the department by 05/03/2021.
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This requirement was not met as evidenced by: interviews. The licensee failed to comply with the regulation referenced above. The facility does not have a phone in a common area for residents to make or receive confidential calls. This poses a potential health, safety, and/or personal rights risk to residents in care.
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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: Danyle WolterTELEPHONE: (916) 708-5307
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/24/2020 and conducted by Evaluator Danyle Wolter
COMPLAINT CONTROL NUMBER: 27-AS-20201224152846

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:
04/19/2021
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Maria Ciscoe, administratorTIME COMPLETED:
01:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility interfering with medical care
Facility restricting resident movements
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Wolter contacted the facility by phone on 04/19/2021 to deliver complaint findings due to COVID-19 and precautionary measures, 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 interfering with medical care and facility restricting resident movements. Documents reviewed revealed the R1 is their own responsible person, 602 for R1 states they are able to leave the facility unassisted but needs transportation to be able to do so. Interviews conducted with facility staff and resident (R1) produced conflicting information.

Due to this information the preponderance of evidence standard has not been met, therefore the above allegations are determined to be UNSUBSTANTIATED.
Exit interview condcuted. Copy of report emailed to administrator, signed copy to be returned to the department. Facility should also retained a signed copy for records.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Danyle WolterTELEPHONE: (916) 708-5307
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3