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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 10:57:54 AM



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
09/30/2020 and conducted by Evaluator Kerry Hiratsuka
COMPLAINT CONTROL NUMBER: 27-AS-20200930132153
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: 49DATE:
04/19/2021
UNANNOUNCEDTIME BEGAN:
10:11 AM
MET WITH:Maria CiscoeTIME COMPLETED:
10:23 AM
ALLEGATION(S):
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2
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9
Facility has not provided refund overpaid rent
INVESTIGATION FINDINGS:
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13
Licensing Program Analyst(LPA) contacted the facility via telephone to deliver complaint finding for the following allegation(s):Resident not receiving medications as prescribed. Finding are delivered via telephone due to COVID-19 and pre-cautionary measures. LPA discussed the purpose of the call and the elements of the allegations with Maria Ciscoe, Administrator.

LPA Hiratsuka reviewed a copy of the admission agreement and interviewed complainant and administrator. Titel 22 regulations regarding refunds state that refunds are required only upon death of a resident, the facility is required to close by Community Care Licensing Division, a court order, or charges an admission fee. The licensee may include their own refund policy as long as it meets the regulations. The regulations do not address a facility's right to waive certain portions of the admission agreement that is in the resident's favor. The admission agreement requires the residents and or responsible party to give 30 day notice to the facility that they are leaving and are required to pay the 30 days.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
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 4
Control Number 27-AS-20200930132153
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
VISIT DATE: 04/19/2021
NARRATIVE
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The administrator waived the 30 day notice and also agreed to refund the days after the resident moved out at her discretion. Administrator stated she kept asking her company about the refund and it took about seven months for it to be issued. Administrator never denied promising the refund and did submit proof that the refund was requested several times and when it was finally issued.

Based on Title 22 regulations not requiring a refund when someone moves out and the facility waiving the notice fees, the allegation is unfounded.

The allegation is UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

An exit interview was conducted with Maria Ciscoe, Administrator via telephone and a copy of this report will be provided to the facility via email. LPA requested Administrator to review the report, sign it, and email a signed copy back to LPA.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
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
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
09/30/2020 and conducted by Evaluator Kerry Hiratsuka
COMPLAINT CONTROL NUMBER: 27-AS-20200930132153

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: 49DATE:
04/19/2021
UNANNOUNCEDTIME BEGAN:
10:11 AM
MET WITH:Maria CiscoeTIME COMPLETED:
10:23 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is unable to locate resident's property
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst(LPA) contacted the facility via telephone to deliver complaint finding for the following allegation(s):Resident not receiving medications as prescribed. Finding are delivered via telephone due to COVID-19 and pre-cautionary measures. LPA discussed the purpose of the call and the elements of the allegations with Maria Ciscoe, Administrator.

LPA Hiratsuka reviewed a copy of the resident inventory list and interviewed complainant and administrator. Resident's belongings were not able to be moved out right away due to covid restrictions. Some of the missing belongings were found, but there is one item left. Administrator is not denying it was in the facility, but Administrator and facility staff were not involved when the resident's belongings were packed up and finally moved out of the facility. The item in question was also not listed on the resident's inventory list for the facility. Because LPA cannot prove or disprove when the item went missing, the allegation is unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
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 4
Control Number 27-AS-20200930132153
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
VISIT DATE: 04/19/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
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24
25
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28
29
30
31
32
An exit interview was conducted with Maria Ciscoe, Administrator via telephone and a copy of this report will be provided to the facility via email. LPA requested Administrator to review the report, sign it, and email a signed copy back to LP
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
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
LIC9099 (FAS) - (06/04)
Page: 4 of 4