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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700301
Report Date: 09/18/2025
Date Signed: 09/18/2025 01:04:49 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/12/2025 and conducted by Evaluator Arielle Pascua
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20250912124600
FACILITY NAME:COUNTRY CLUB MANORFACILITY NUMBER:
342700301
ADMINISTRATOR:KATHRYN NEVINFACILITY TYPE:
740
ADDRESS:2100 BUTANO DRIVETELEPHONE:
(916) 481-9240
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:112CENSUS: 55DATE:
09/18/2025
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Kathryn Nevin TIME COMPLETED:
01:30 PM
ALLEGATION(S):
1
2
3
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5
6
7
8
9
Staff are inappropriately locking facility doors.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 09/18/2025, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a complaint visit. LPA met with Facility Designated Administrator (FDA), Kathryn Nevin and explained the purpose of the visit. The purpose of this visit was to inform the facility and it's representative that a complaint has been filed against it at this time.
Current census was 55. A brief interview with FDA Nevin was conducted.
It was alleged that facility staff are inappropriately locking facility doors. Based on interviews conducted, it was denied that the facility staff are inappropriately locking facility doors. It was stated that the facility doors are closed after 8:00pm, however, the facility residents have access to go through the doors. In addition, LPA Pascua reviewed facility video recordings and did not find that the facility staff was locking the facility doors. LPA Pascua observed the doors to be easily accessible to the residents in care.
Based on the information gathered, there is not sufficient evidence to show that the facility staff inappropriately lock facility doors. As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred.
There were no deficiencies observed or cited at this time. An exit interview was conducted, a copy of the 9099 was provided to the facility at the end of this visit.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2025
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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