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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700301
Report Date: 07/07/2026
Date Signed: 07/07/2026 05:17:31 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
10/07/2025 and conducted by Evaluator Christina Valerio
COMPLAINT CONTROL NUMBER: 27-AS-20251007110723
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: 60DATE:
07/07/2026
UNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Kathryn Nevin TIME COMPLETED:
05:40 PM
ALLEGATION(S):
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Facility rails are a hazard to residents.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christina Valerio and LPA Reza Jamaly arrived to the facility unannounced to conduct a complaint investigation and deliver complaint findings.

The following has been determined as it relates to aforementioned allegation: Facility rails are a hazard to residents.

On 10/13/2025, LPA Viarella conducted an interview with the Reporting Party (RP). The RP informed LPA Viarella that the handrail by the medication room has chunks missing and could cause a skin tear or splinters for residents. On 10/15/2025, LPA Viarella conducted an unannounced visit. LPA Viarella inspected the hand railing that travels the walls around the interior of the facility. According to LPA Viarella's observation notes, LPA Viarella obtained a splinter in her right hand after running her hand along the railing to test if it was a danger to residents.
Continues on LIC 9099 - C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2026
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 8
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: 07/07/2026
NARRATIVE
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On 07/07/2026, LPA Valerio conducted an unannounced visit. LPA Valerio inspected the hand rails around the interior of the facility. LPA Valerio observed many handrails to have chunks of wood missing from the handrail. One handrail was observed to have a piece of the hand rail missing, which exposed two needles or staples.

Based on interview and observation, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8) are being cited on the attached LIC-9099D. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided. An exit interview was conducted, and a copy of the report was left at the facility.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 8
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/07/2026
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement was not met as evidenced by:
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Licensee stated the facility will have the maintenance staff inspect the handrails and repair as needed and remove any hazards. LPA Valerio to receive pictures of repaired handrails by POC due date.
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Based on observations on 10/15/2025 and 07/07/2026, the facility handrails were not in good repair, which posed a potential health and safety risk to residents 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.
SUPERVISOR'S NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 8
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 MANORFACILITY NUMBER:
342700301
ADMINISTRATOR:KATHRYN NEVINFACILITY TYPE:
740
ADDRESS:2100 BUTANO DRIVETELEPHONE:
(916) 481-9240
CITY:SACRAMENTOSTATE:CAZIP CODE:
95825
CAPACITY:112CENSUS: 60DATE:
07/07/2026
UNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Kathryn Nevin TIME COMPLETED:
05:40 PM
ALLEGATION(S):
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Staff does not provide resident with linens.
Staff does not keep resident’s room free from pest.
Staff not keeping resident’s room free from odor
Staff did not properly dispose urine.
Staff not maintaining resident’s hygiene.
Staff does not provide nutritious meals
Staff does not offer fresh fruits and vegetables. 
Staff does not provide comfortable sleeping arrangement for resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christina Valerio and LPA Reza Jamaly arrived to the facility unannounced to conduct a complaint investigation and deliver complaint findings. The investigation was assigned to LPA Viarella and then LPA Valerio. The investigation consisted of interviews with the Reporting Party (RP), interview with staff, interview with residents, and facility record review of Resident 1 (R1) Medication Administration Record, R1 Incident Reports, Facility Dietitian Report Cards, and Pest Control Invoices/ The following has been determined as it relates to aforementioned allegations.

Staff does not provide resident with linens.

According to the RP, the facility did not provide linens for Resident 1 (R1).
On 10/15/2025, LPA Viarella conducted an unannounced visit. LPA observed linens on resident beds.

Continues on LIC 9099 - C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 8
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: 07/07/2026
NARRATIVE
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On 07/07/2026, LPA Valerio conducted an unannounced visit. R1 no longer lives at the facility and therefore, the room was unoccupied. LPA Valerio conducted an inspection of four (4) resident bedrooms. LPA Valerio observed clean linens and bedsheets in each bedroom. LPA Valerio observed a supply closet that was fully stocked with bed sheets, comforters, towels, and pillow cases.

Staff does not keep resident’s room free from pest.      
According to the RP, the R1's bedroom was full of dead bugs. There were dead bugs in the closet and in the bathroom.
During LPA Viarella's unannounced visit on 10/15/2025, LPA Viarella did not indicate the observation of pest or bugs in R1's room.  LPA did not see any insects (alive or dead) and the entire room did not look like it had been vacuumed in some time as evidenced by the dust and debris.  During this visit, Pest Control Invoices were collected for review.
LPA Valerio observed the facility to received pest control services on 08/11/2025, 09/08/2025, and 10/02/2025. According to an interview with Staff 1 (S1), the pest control service provider, Aantex Pest Control, continues to service the facility monthly. In addition to this pest control provider, they have an additional pest control service that services individual rooms when requested by the facility. According to an interview with Staff 2 (S2), the facility will be having the pest control service come out to spray the rooms. There is not a specific bug/pest they are targeting and it is more for maintenance.

Staff not keeping resident’s room free from odor// Staff did not properly dispose urine.   
 According to an interview with the RP, the RP stated that R1's room had an odor due to two buckets of old urine under R1's bed.

During LPA Viarella's unannounced visit on 10/15/2025, LPA Viarella did not indicate the observation of odors.  LPA observed that the carpet was heavily stained and was in the process of being pulled up from the baseboard; however, there were no odors.  During LPA Viarella's unannounced visit on 10/15/2025, LPA Viarella did not indicate the observation of buckets of urine located under the bed. However, it should be noted that R1 was removed from the facility by R1's
LPA Valerio conducted an unannounced visit on 07/07/2026. LPA did not observed buckets of urine under any bed in the bedrooms inspected during the tour.

Continues on Page 3
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 8
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: 07/07/2026
NARRATIVE
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Staff not maintaining resident’s hygiene.
According to the RP, R1 was not provided a shower for weeks and the bathroom door stated that the bathroom could only be used for room 41, which wasn’t R1's room.
According to LPA Viarella's observation the bathroom located inside of R1's room was a shared bathroom. The bathroom did not have a shower and it was solely a toilet.
According to an interview with S1, they had one resident diagnosed with scabies and that specific shower room was being used by that individual until they were clear of scabies. 
According to S1, R1 would have been provided a shower that was not utilized by the individual diagnosed with scabies.
According to R1's care plan dated 09/15/2025, R1's bathing service showed the following: hands -on help with bathing, assistance with bathing 2x per week, needs a shower chair, and the frequency is as scheduled and completed by a caregiver or med-tech.

Staff does not provide nutritious meals/Staff does not offer fresh fruits and vegetables. 
According to the RP, the facility did not offer fresh fruit or vegetables.
On 10/15/2025, LPA Viarella took pictures of Clementine's, pineapples, bananas, oranges, asparagus, cucumbers, and boxes of more vegetables being unloaded as it was their delivery day. On 07/07/2026, LPA Valerio observed strawberries, fruit cups, oranges, mandarins, asparagus, celery, salad, fruit cocktail, and plates of cobb salad.

According to Consultant Dietitian Report Cards dated July and November of 2025, the facility scored 100% in the category Nutrition Care. According to the report dated July 2025, "lunch meal Swedish meatballs, parsley noodles, buttered carrots, roll and whipped gelatin parfait. The two mechanically altered diets were prepared according to residents preferences.". According to the report dated November 2025, "lunch meal - meatballs with marinara, spaghetti, tossed salad, garlic bread, sherbet. Residents were very happy with meal. Tasted and temperature were good. Puree diet texture appropriate"

Continues on Page 4
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 8
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: 07/07/2026
NARRATIVE
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Staff does not provide comfortable sleeping arrangement for resident.
According to the RP, R1 had been "sleeping up" for the last two months and was tired. The RP reported that the facility had a mattress but it went missing. According to an interview with S1, S1 stated they provided many options for R1; however, R1 did not like the hospital bed and preferred to sleep in a reclining chair. We offered R1 different beds but R1 did not like them. According to facility records, R1 moved out of the facility in October and is no longer a resident of the community.

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: 07/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2026
LIC9099 (FAS) - (06/04)
Page: 7 of 8