342700301-7-20-2026-27-AS-SRIN-DWGR7J-20260730124624

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700301
Report Date: 07/20/2026
Date Signed: 07/20/2026 12:39:28 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
10/07/2025 and conducted by Evaluator Christina Valerio

COMPLAINT CONTROL NUMBER: 27-AS-20251007110723

FACILITY NAME:	COUNTRY CLUB MANOR		FACILITY NUMBER:	342700301
ADMINISTRATOR:	KATHRYN NEVIN		FACILITY TYPE:	740
ADDRESS:	2100 BUTANO DRIVE		TELEPHONE:	(916) 481-9240
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95825
CAPACITY:	112	CENSUS: 60	DATE:	07/20/2026
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Kathryn Nevin		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not provide medical attention to resident in a timely manner.
Staff mismanaging resident’s medication.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to deliver complaint findings. LPA Valerio met with Administrator Kathryn Nevin, and explained the purpose of the visit.

Allegation: Staff did not provide medical attention to resident in a timely manner.

According to the RP, R1 requested to go to the hospital. RP asked staff to call 911. RP saw staff make a call. RP waited outside with R1 for paramedics to arrive. RP stated 10 minutes later a staff member (name unknown) came out and informed RP they would not call 911 and refuse to call. Staff closed and locked the door. RP then flagged down paramedics who then called 911 for R1. Based on review of an interview conducted by LPA Viarella, the RP did not disclose the date of this incident. LPA Valerio attempted to contact RP but was unsuccessful. LPA Valerio requested from the facility all incident reports regarding R1.

Continues on LIC 9099 -C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2026

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-20251007110723

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: 07/20/2026

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

According to an interview with S1, S1 stated that R1's RP wanted R1 to go to the hospital because R1's bed was uncomfortable. S1 stated that it was not a medical emergency so we could not send R1 out. S1 checked the video footage and S1 did not see anyone ever ask the staff to send R1 out.

LPA Valerio reviewed two incident reports received from the facility.

Incident 1, dated 10/01/2025, stated R1's POA dropped resident off at the facility after R1 being out for the day. POA then came barging into the med room about R1 not sleeping in R1's bed. POA then started hollering at the med techs accusing them of not doing their job and stating R1 needed a new bed right now or R1 needs to go to the hospital. Med techs kindly explained to POA that they are not able to switch beds and to reach out to the administrator. POA was noted to take R1 to the emergency room. R1 came back at 7:52AM on 10/02/2025 from the hospital with a dx of pain in lower extremities and physical deconditioning. Staff noted on the incident report that the R1's bed has been switched out 3 times, 2 different hospital beds, and a regular bed, which R1 did not like. R1 has been up and about today. No complaints of pain or discomfort in R1's legs.

LPA Valerio reviewed hospital after visit summary dated 10/01/2025. LPA Valerio confirmed the information that was relayed on the incident report was also stated on the after summary.

Incident 2, dated 10/02/2025, stated R1's POA stated POA was coming down to the facility to pick up the resident to take R1 to the hospital since POA did not feel comfortable leaving R1 at the facility due to the lack of a comfortable bed and feels POA would be neglecting R1 if R1 is left at the facility. POA took R1 out of the facility at 7:00 PM. On the incident report, staff indicated that there were no medical needs mentioned. According to staff, "resident prefers to sleep in recliner and PCP sent [doctors] orders for resident to sleep in recliner on 10/03/2025." Staff indicated that R1's case manager reached out to the facility stating the ER wants to discharge R1 but are holding R1 until alternative placement is found."

Continues on LIC 9099 - C, page 3

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 27-AS-20251007110723

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: 07/20/2026

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Allegation: Staff mismanaging resident’s medication.

According to records review, R1 is able to determine need and communicate need clearly for PRN medications and has a service plan of full assistance with medication management. LPA Valerio reviewed the Medication Administration Record (MAR) for September and October of 2025. LPA Valerio did not observe any discrepancies for the September or October MAR.

Based on all the information collected by the Department, although the allegation may have happened or is valid, here is not a preponderance of evidence to prove the allegation occurred, therefore this allegation is UNSUBSTANTIATED. California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. Exit interview was held and a copy of report was left at the facility.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 3