342700301-5-10-2021-27-AS-KHOS-C2WND7-20210511102151

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700301
Report Date: 05/10/2021
Date Signed: 05/10/2021 11:52:44 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
12/29/2020 and conducted by Evaluator Danyle Wolter

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20201229125636

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: CA	ZIP CODE:	95825
CAPACITY:	112	CENSUS: 49	DATE:	05/10/2021
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Maria Ciscoe, administrator		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Staff did not communicate facility Covid-19 guidelines, to resident and her authorized representative.
Staff are being misguided to believe that resident has dementia.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Wolter contacted the facility by phone on 05/10/2021 due to COVID-19 and precautionary measures to deliver complaint findings for complaint Community Care Licensing (CCL) received on 12/29/2021, LPA spoke to Administrator Maria Ciscoe and explained the purpose of the call.

Throughout the course of the investigation CCL conducted interviews and reviewed documentation relevant to the allegations: Staff did not communicate facility Covid-19 guidelines, to resident and her authorized representative and Staff are being misguided to believe that resident has dementia. Witness (W1) alleged that no further information was provided when they asked about quarantine guidelines from the facility beyond positive residents being quarantined in their rooms for 14-days and then tested again, W1 stated when they asked for further information they were told, “I don’t know.”

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: 05/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2021

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-20201229125636

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: 05/10/2021

NARRATIVE

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In interviews with staff CCL was told that residents and their responsible parties were notified of the COVID-19 outbreak and quarantine guidelines, CCL was further told that responsible parties were also informed of CCL’s PIN for any further questions. Documentation reviewed revealed that resident (R1) tested positive for COVID-19 and a charting note from 12/08/2020 notes their responsible party was informed. R1’s 602 does not have a diagnosis of dementia but notes from an outside Registered Nurse (RN) were reviewed and revealed that R1 has expressed concerns with memory impairment. However, R1 has not been diagnosed by a physician to have dementia.

Due to this information the preponderance of evidence standard has not been met, therefore the above allegations are determined to be UNSUBSTANTIATED.

Exit interview conducted. Copy of report emailed to administrator, signed copy to be returned to the department. Facility should also retained a signed copy for records.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Danyle Wolter	TELEPHONE: (916) 708-5307
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2021

LIC9099 (FAS) - (06/04)

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