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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700301
Report Date: 03/20/2026
Date Signed: 03/20/2026 02:42:51 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
02/02/2026 and conducted by Evaluator Cynthia Tamayo
COMPLAINT CONTROL NUMBER: 27-AS-20260202111051
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:
03/20/2026
UNANNOUNCEDTIME BEGAN:
12:18 PM
MET WITH:Karla Celina Rosete Ayala TIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Lack of supervision resulting in resident sustaining fractures.
Staff left resident in soiled in clothing for a period of time.
INVESTIGATION FINDINGS:
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On 3/20/26, Licensing Program Analyst (LPA) Cynthia Tamayo arrived unannounced to complete and close the investigation into an allegation noted above. LPA met with Medication Technician, Nickolas Townsend(S3), and Resident Care Coordinator, Karla Celina Rosete Ayala (S2) and stated the purpose of this visit. An entrance interview was conducted

Allegation: Lack of supervision resulting in resident sustaining fractures.
This investigation focused on Resident 2 (R2) Throughout the process, LPA conducted facility observations interviewed on duty staff and residents, collateral interviews, and reviewed all relevant documents related to R2.

Per R2's LIC 602, physicians’ report dated 8/2025, R2 is noted as ambulatory. R2’s care plan dated 9/11/2024 they are noted as “Independent with transferring” as well as independent with changing and toileting. Additionally, it indicates R2 needs assistance with bathing - 2x per week with use of a Shower chair and assistance with medications.
CONTINUED ON 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Cynthia Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2026
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 3
Control Number 27-AS-20260202111051
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: 03/20/2026
NARRATIVE
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Hospital records confirm R2 obtained two broken ribs and was admitted on 1/31/26. It was also reported that R2 was stiff when staff tried to assist them with repositioning.

Administrator, Kathryn Nevin (S1) stated that R2 fell on 1/31/26, 2/5/26, and 12/13/26. S1 stated that R2 was not utilizing any assertive devices for walking prior to 1/31/26 and did not have a history of falls, they were not a fall risk.
Per incident report (SIR) received on 1/31/26, R2’s was immediately sent to the hospital upon R2 reporting that they had fallen the night prior but did not request assistance until medication pass around 8:00AM. Staff 3 (S4) reported that R2 was covered with their blankets so they were unable to see if R2 was soiled. On 3/20/26, Med tech, S4 stated on shift on 1/31/26 stated they went into R2’s room in the morning to give him his medications and that is when R2 reported they fell at 2:00AM on 1/31/26 and was able to get himself up so they did not call for help. staff called the paramedics to have R2 be evaluated at the hospital as he was complaining of pain, S4 stated R2 stayed in their bed covered by their blankets until the paramedics arrived.

Discharge paperwork received for R2's hospital visits on 1/31/26 and 2/5/26. The facility created a new care plan/appraisal on 2/5/26 done due to the change in condition. R2 started. receiving physical therapy and get more assistance since. The updated plan stated “Safety checks - 4 times per shift” and R2 now uses a walker in which they need verbal reminders and cuing to use. S2 stated R2 fell on 1/31/26, 2/5 and 2/13, in which a re-assessment of needs was made for this change of condition. On 3/202/6, R2 stated they don’t like to use the call button unless they really need it, their needs are being met at this facility, and they feel safe.

Per Department led record review of R2s care plan and incident reports it was found that R2 does not have a history of falls. 3 out of 3 staff interviewed sated R2 did not require constant supervision as they were mostly independent prior to falling on 1/31/26 and there is increased supervision ever since February 2026.

S2 stated that R2 has a new care plan effective 2/18/2026 and currently receives skilled nursing, physical therapy, and occupational therapy, 2 hours checks by care staff, shower assistance, and uses a walker. S1 stated R2 is using their walker more often as staff encourages them to do so. R2 confirmed they are using a walker "for long distance" and have a working call button. On 3/20/26, LPA Tamayo observed a care staff arrived to R2's bedroom within four minutes of the button being pressed (12:41PM -12:45PM). Authorized representative for R2 stated they have no concerns about the facility, they are “grateful” for the care and supervision provided by the facility. LPA observed the call button is fixed to the wall behind a chair and night stand. S3 stated that staff tried to rearrange their room to make the call button more accessible, however R2 did not want their room rearranged.

CONTINUED ON 9099-C2
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Cynthia Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20260202111051
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: 03/20/2026
NARRATIVE
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S2 plans to talk to maintenance to get a longer pull string for the call button or if it can be relocated. S3 is also seeing if a hospital bed is possible to obtain to allow for the call button. S2 stated that wearable pendant buttons is not currently a service offered at the facility but S3 will look into whether they can get one for fall risk residents. The new care plan involves more supervision with more frequent checks, every two hours.
S1 stated an incident report was sent in on 2/17/26 to the Regional Office for another witnessed fall on 2/13/26 in which there was a diagnosis of closed fracture above inner left wrist (distal radius). A fall risk assessment was completed by the facility on 2/18/26. Facility provided the Department with fall risk assessment. Based on interviews and record review of the LPA and review of records the allegation that "Lack of supervision resulting in resident sustaining fractures", is unsubstantiated.

Allegation Staff left resident in soiled in clothing for a period of time.
This investigation focused on Resident 1 (R2) Throughout the process, LPA conducted facility observations interviewed on duty staff and residents, collateral interviews, and reviewed all relevant documents related to R2.
It was alleged that R2’s "clothing was soiled and dirty, his shirt had vomit from over 24 hours and had not been changed". Per incident report received on 1/31/26, R2’s was sent to the hospital upon R2 reporting that they had fallen the night prior but did not request assistance or tell staff they had a fall until medication pass around 8:00AM. Medication Technician Staff 4 (S4) reported that R2 was covered with their blankets so they were unable to see if R2 was soiled. 3 out of 3 staff stated R2 was complaining of pain and they stayed in bed until the paramedics arrived, there was no observation of R2 being in soiled. R2 stated their hygiene needs are met, although they want to be independent, staff assisted with bathing and laundry. On 3/20/26, LPA observed that R2s room was clean and free from odor and R2s clothing was clean and did not have any odors. LPA conducted a collateral interview with R2's family member (R1), they stated that R2 does not have any concerns about resident being left in soiled in clothing for a period of time. Based on interviews and record review of the LPA and review of records and the allegation was not corroborated and the allegation "Staff left resident in soiled in clothing for a period of time" is unsubstantiated.

Based on the interview statements and record review obtained during the investigation process, there is not a preponderance of the evidence to prove that the alleged violation that staff did not ensure staff coverage documentation accurately reflects the actual hours worked by staff occurred and is unsubstantiated. Although the Department has determined that the allegations above are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed.

There are no deficiencies cited per California Code Regulation, TITLE 22. Exit interview was conducted with the S2. Appeal Rights were issued, and a copy of this report was left at the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Cynthia Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3