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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700301
Report Date: 02/03/2026
Date Signed: 02/03/2026 12:24:03 PM

Substantiated


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
12/14/2025 and conducted by Evaluator Noel Wolf Petersen
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20251214210439
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: 54DATE:
02/03/2026
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Kaithryn NevinTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff are mishandling the residents medications
INVESTIGATION FINDINGS:
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Licensing Program Analyst, LPA, Noel Wolf Petersen arrived to the facility unannounced to conduct a complaint investigation into the above allegation. LPA met with administrator Kathryn Nevin, and explained the purpose of the visit.
Through record review and interview and observation by the LPA, it was learned that the facility medication administration documentation is not detailed in the specific ways outlined by regulation, or left undetailed. 5 MAR records chosen at random, one MAR record showed a clients refusal documentation reasoning as "ref" mean refused, which is not useful in determining the reasoning for the refusal. For 2 MAR records, it is marked that the facility is unable to disperse a medication by flag "other" or "medication not availible", but a readily availible Notes coloumn does not describe the reasoning of the medication not being availible or whats being done about it or what will be done about it. In interview, some staff are reporting not enough time on shifts with less Med Techs assigned to stay on top of documentation tasks. On two occassions LPA observed alerts in the MAR that were unanswered for marking down PRN dispersal results timely, one of the alerts was observed for a medication given 3 hours earlier.
continued on C page
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Noel Wolf Petersen
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2026
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-20251214210439
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: COUNTRY CLUB MANOR
FACILITY NUMBER: 342700301
VISIT DATE: 02/03/2026
NARRATIVE
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LPA gave guidance that the reason for refusal should be documented as outlined in regulation, PRN response fields of documentation should be completed timely, any staffing concerns should be raised in the internal grievance process, and documentation should be filled out with the goal to reduce reliance on verbal reporting not to make it mandatory.

Based on LPAs observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, is being cited on the attached LIC 9099D.

citations issued, a copy of the appeal rights was left with the administrator. a copy of the report was read and given to the administrator.

Exit interview conducted.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Noel Wolf Petersen
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
12/14/2025 and conducted by Evaluator Noel Wolf Petersen
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20251214210439

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: DATE:
02/03/2026
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Kaithryn NevinTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff members consume alcohol/drugs during work hours, impairing their ability to provide adequate care and supervision, which presents a risk to the residents
Staff is providing services not properly trained for
Staff is not following medical orders for the residents
Staff is altering the residents records without proper authorization
INVESTIGATION FINDINGS:
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Licensing Program Analyst, LPA, Noel Wolf Petersen arrived to the facility unannounced to conduct a complaint investigation into the above allegations. LPA met with administrator Kathryn Nevin, and explained the purpose of the visit.
by interview with staff/clients, it was learned that an event was hosted by the facility activity director which included alcohol. one client accounts being made uncomfortable with the independant living activity director consuming any alcohol, some clients account not experincing any discomfort with the independant living activity director consuming alcohol. No clients report observing intoxicated or inebriated behavior from the independant living activity director.
By interview with staff/clients and record review of training matierals, it was learned that the facility takes blood pressure readings with med tech staff. Some clients account being uncomfortable with the blood pressure reading being within the scope of practice for med tech staff and raise concerns about med techs making diagnostic type decisions related to the reading of the blood pressure for example, taking a reading of the blood pressure and then choosing to hold or disperse a blood pressure medication. Staff report that the blood pressure readings are taken by med techs. LPA gave guidance that decisions related to holding or dispersing a medication lie with a nurse/doctors consult, which is-
continued on c page.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Noel Wolf Petersen
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2026
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 5
Control Number 27-AS-20251214210439
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: COUNTRY CLUB MANOR
FACILITY NUMBER: 342700301
VISIT DATE: 02/03/2026
NARRATIVE
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documented, or with the client refusing or accepting a medication. Over three med pass observations, LPA did not witness the staff withold a medication, based on the blood pressure reading or not.

By interview with staff/clients, and a record review of MARs and the facility menu, and meal observation, it was learned that medication is confiscated by staff when they arrive to the facility if it is not on the medication orders list. In at least one instance, a client reported the staff taking a medication perscribed to her and not dispersing it. It was learned from the mar that a discontinue order for that medication was issued 2 days before the client arrived. The facility staff do not have a response as to what happened to the medication after it was confiscated, if it was destroyed, if it was kept secure as property of the client. LPA gave guidance that kind of confiscation policy should be more obvious to the incoming clients in the form of an addendum to the admission agreement and the issue should be resolved internally as a loss of property if it cannot be produced by the facility. As a related issue, some clients (a mixed population of nonassisted living, and assisted living) report not being given the option of adequately nutritious alternatives if they have a perscribed alternative diet. LPA reviewed the menu and observed the lunch service on two occasions, the lunch service is meeting the nutritional requirement of 1/3 of servings of the various groups in the regular and alternative meals, LPA is concerned about anybody repeatedly choosing the house salad option not getting an adequate amount of protein. LPA gave guidance that the salad can easily have servings of nuts, cheese, eggs, or chicken added to it to shore up any nutritional concerns and improve the variety for the hypertensive/diabetic folks. cheese cant be used as a source of protien if its also being used as a source of dairy for the purposes of menu design.

by interview with staff/clients, it was learned that holds are given of the clients medication. some clients report unease with the facility issuing medication in general and specificly the practice of holding the medication. The staff report that they do not give out medication belonging to other residents, or give out medication that is ordered by a doctor to be withheld, and destroy medications as necessary when a client has a new order/leaves the facility permanently. The practice of holding medication is specificly for unplanned absences from the facility. LPA gave guidance that medication is the clients property and should go with the client if they have a planned absense from the facility, they or a responsible party (as applicible) can sign out their medication with a affidavit that they will adhere to the schedule of the medication. The facility has a responsibility to take measures to ensure medications are delivered on schedule, and medications are not to be used to restrict the movement of the clients.
Although the allegation(s) may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. no citation issued, A copy of the report was read and given to the administrator, appeal rights provided. exit interview conducted
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Noel Wolf Petersen
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Citations on this Visit Report are Under Appeal!

Control Number 27-AS-20251214210439
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: COUNTRY CLUB MANOR
FACILITY NUMBER: 342700301
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type B
02/10/2026
Section Cited
CCR
80075(b)
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80075 Health Related Services (b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement was not met as evidenced by:
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Licensee will review current documentation practices, propose a strategy in writing to the LPA that addresses the concerns, by the poc date. noel.wolfpetersen@dss.ca.gov
LPA is suggesting better and consistant use is made of the "notes" feature on the online mar.
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Record review and interview and observation by the LPA, where 3 of 5 records requested at random had incomplete or unusable documentation, 1 unusable reasoning of refused medication and 2 missing PRN reasoning. This posed a potential risk to the health, safety or personal rights of the clients 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.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Noel Wolf Petersen
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5