Inspection Reports for Country Club Manor

An unannounced complaint investigation visit was conducted in response to an allegation that facility staff were inappropriately locking facility doors.

The investigation found no evidence that facility staff were inappropriately locking doors. Interviews and video review confirmed that doors were accessible to residents, and the allegation was unsubstantiated.

The complaint alleged that staff were inappropriately locking facility doors. The allegation was found to be unsubstantiated based on interviews and video evidence.

An unannounced complaint investigation was conducted in response to an allegation that a resident felt pressured to sign a payment plan.

The investigation found that the resident was aware of their financial obligations and signed the payment plan despite concerns about their ability to pay. Interviews with involved parties indicated no evidence of coercion. The allegation was determined to be unsubstantiated and no deficiencies were cited.

The complaint alleged that a resident felt pressured to sign a payment plan. After investigation, including interviews with the resident, Executive Director, Business Office Manager, and Regional Director, the allegation was found unsubstantiated due to lack of preponderance of evidence.

Unannounced annual visit conducted on 06/30/2025 by Licensing Program Analyst Charlie Yang to evaluate compliance with licensing requirements at Country Club Manor facility.

The facility was toured including living areas, kitchen, medication room, bedrooms, restrooms, laundry, and exterior grounds. All areas and supplies were found to be sufficient, in good repair, and in compliance. No deficiencies were observed or cited during this annual visit.

An unannounced required annual inspection was conducted to evaluate the facility's compliance and status during ongoing renovations.

The facility was unoccupied due to renovations, which were superficial and did not alter the structure. No deficiencies were issued during the inspection, and the facility had operating utilities and required furniture.

An unannounced complaint investigation was conducted following a complaint received on 08/05/2024 regarding multiple allegations including failure to notify responsible parties of incidents, lack of supervision leading to resident assaults, and failure to protect residents from physical attacks.

The investigation substantiated that the facility failed to notify the responsible party of an incident, did not provide adequate supervision resulting in multiple assaults between residents, and failed to implement an effective plan to protect residents from further attacks. One allegation regarding staff training on dementia care was found unsubstantiated.

The complaint investigation was substantiated based on evidence that the facility failed to notify the responsible party of a stabbing incident, failed to provide adequate supervision resulting in multiple assaults, and failed to implement a protective plan. The responsible party was notified late by the Ombudsman, and the facility's Executive Director admitted to insufficient monitoring. The allegation that staff were not trained to care for residents with dementia was unsubstantiated.

An unannounced case management visit was conducted following an incident where resident R2 stabbed resident R1 in the face with a fork during dinner on 07/24/24. The visit aimed to review incident reporting and compliance with regulations.

The facility failed to notify the responsible party and primary care physician of resident R1 despite documentation indicating otherwise, posing a potential threat to resident safety. Additionally, resident R2's annual reappraisal was overdue. Deficiencies were cited related to false claims in documentation and failure to conduct timely reappraisals.

The visit was complaint-related due to an incident where R2 stabbed R1 with a fork. The complaint was substantiated by findings that the facility failed to properly notify responsible parties and physicians as required.

An unannounced annual required inspection was conducted to ensure compliance with Title 22 regulations.

The facility was found to be in compliance with no health or safety concerns observed. Resident rooms and common areas were clean and well-maintained, staff files and resident files were current, and medications and hazardous materials were properly secured.

An unannounced complaint investigation was conducted due to allegations that staff were not providing residents with a comfortable environment.

The investigation found that one resident with vision impairment was unable to effectively use the single emergency pull chord in a shared room, resulting in frequent loud calls for assistance that disturbed other residents. This behavior caused discomfort and agitation among nearby residents, interfering with their daily activities and sleep.

The complaint was substantiated based on the preponderance of evidence. The allegation that staff were not providing residents with a comfortable environment was found valid.

Unannounced complaint investigation visit conducted in response to allegations including staff mismanaging resident's medication, refusal to provide proper bedding, and untimely assistance to residents.

The investigation found that the facility was following physician's orders for medication administration, housekeeping and laundry services were adequate, and staff responded appropriately to resident pull cord alerts. The allegations were determined to be unsubstantiated with no deficiencies observed or cited.

Complaint allegations were found to be unsubstantiated, meaning there was not a preponderance of evidence to prove the alleged violations occurred.

The inspection was an unannounced annual visit conducted to evaluate the facility's compliance and licensing status.

No deficiencies were cited during the visit. The facility was undergoing extensive remodeling with no residents present at the time. Required signs and appropriate furnishings were observed throughout the facility.

This was an unannounced complaint investigation visit triggered by a complaint received on 2023-11-06 alleging that staff did not meet a resident's hygiene needs.

Based on interviews with residents and staff, record reviews, and observations, the allegation that staff did not meet a resident's hygiene needs was determined to be unsubstantiated. No deficiencies were cited during this visit.

The complaint alleged that staff did not meet a resident's hygiene needs. The investigation included interviews with five residents and eight staff members, and review of resident R6's records and daily notes. The allegation was found unsubstantiated due to lack of preponderance of evidence.

Unannounced complaint investigation visit conducted in response to allegations including untimely medication ordering, lack of glove use during food preparation, inadequate food service, and mismanagement of narcotic medication.

Based on interviews, observations, and record review, the allegations were found to be unsubstantiated with no deficiencies cited. Staff were observed following proper procedures for medication ordering, narcotic counts, hygienic food preparation, and dietary order compliance.

The complaint investigation was unsubstantiated, meaning there was not a preponderance of evidence to prove the alleged violations occurred.

An unannounced complaint investigation was conducted in response to allegations received on 11/15/2023 regarding improper sanitation of facility grounds, maintenance of resident rooms, pest control, and addressing changes in a resident's medical condition.

The investigation found no evidence to support the allegations. Housekeeping and maintenance were observed performing duties, pest control treatments were up to date, and resident care practices including laundry schedules were confirmed. The complaint was deemed unfounded with no deficiencies cited.

The complaint was investigated and found to be unfounded, meaning the allegations were false or without reasonable basis. No deficiencies were observed or cited.

The visit was an unannounced complaint investigation conducted to address multiple allegations received on 08/31/2023 regarding facility trash bin lids, financial abuse, medication administration by unqualified staff, resident clothing cleanliness, administrator presence, and meal provision.

The investigation found four allegations unsubstantiated: staff not securing trash bin lids, financial abuse of residents, unqualified staff administering medications, and residents not dressed in clean clothing. Two allegations were substantiated: the facility administrator was not present for a sufficient number of hours, and staff did not ensure residents were eating meals, with meal logs showing discrepancies.

The complaint investigation was triggered by allegations including unsecured trash bin lids, financial abuse, unqualified medication administration, unclean resident clothing, insufficient administrator presence, and failure to ensure residents ate meals. The investigation involved interviews with residents and staff, observations, and records review. Four allegations were unsubstantiated, and two were substantiated.

The inspection was an unannounced complaint investigation visit conducted to investigate allegations received on 2023-09-06 regarding staff not adhering to resident care plans, failure to provide medications, staff retaliation, and medication errors.

The investigation found no evidence to substantiate the allegations that staff failed to adhere to care plans, did not provide medications, or retaliated against residents. The allegation of staff administering the wrong medication was found to be unfounded. Resident interviews, record reviews, and staff interviews supported these conclusions.

The complaint investigation was unsubstantiated, meaning there was not a preponderance of evidence to prove the alleged violations occurred. One prior substantiated medication mismanagement incident was noted from 4/6/2023, but no recent incidents were found. The allegation of staff retaliation was not supported by evidence.

An unannounced complaint investigation visit was conducted to investigate an allegation that staff behavior poses a risk to residents while in care.

The investigation found insufficient evidence to support the allegation. Interviews with residents and staff revealed some concerns about alcohol smell on a staff member, but no proof of intoxication or risk to residents was found. The complaint was determined to be unsubstantiated.

The complaint alleged that staff behavior posed a risk to residents. The investigation included interviews with 4 residents and 5 staff members. Two staff reported smelling alcohol on a staff member, who denied intoxication. The allegation was found unsubstantiated due to lack of evidence.

An unannounced complaint investigation was conducted in response to allegations that the facility was serving expired food to residents and that staff levels were insufficient to meet resident needs.

The investigation found the allegations to be unsubstantiated. No expired food was observed during multiple inspections, and interviews with residents and staff indicated that resident needs were being met with adequate staffing levels. No deficiencies were cited.

The complaint was unsubstantiated based on interviews with nine residents and six caregivers, inspections of food supplies, and review of staffing levels. The Department determined that the allegations of Personal Rights violations were unsubstantiated but noted the complaint could be amended if additional information is received.

An unannounced complaint investigation was conducted in response to allegations received on 2023-05-12 regarding inadequate care and supervision, mishandling of medication, and mishandling of a resident's confidential information at Country Club Manor.

The investigation found no substantiation for the allegations after interviews, record reviews, and observations. Medication handling was appropriate, resident records were secure, and staff denied the alleged violations. The complaint was determined to be unsubstantiated or unfounded with no deficiencies cited.

The complaint was unsubstantiated and unfounded. Allegations included inadequate care and supervision, medication mishandling, and mishandling of confidential information. Interviews with residents and staff, medication log review, and record security checks found no evidence to support the allegations.

An unannounced case management inspection was conducted to address areas of facility improvement.

The inspection found one bathroom in room 107 without required grab bars, with a work order scheduled to correct this. Residents expressed disappointment with food service, and advisory notes were provided to discuss menu and food preferences at the next resident council. No deficiencies were cited under California Code Regulation, TITLE 22.

Unannounced visit to investigate a complaint received on 2023-04-13 regarding allegations that the facility did not assist a resident with prescribed medication and other related concerns.

The investigation substantiated a prior finding of staff mismanaging resident medication on 2023-04-06 but did not cite any new deficiencies. Other allegations including failure to communicate with conservator, denial of resident pharmacy choice, failure to assist with medical care, failure to provide resident records, and failure to notify responsible party of condition changes were found unsubstantiated.

Complaint investigation was substantiated for staff mismanaging resident medication on 4/6/2023. Other allegations were unsubstantiated due to lack of preponderance of evidence.

The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2023-05-03 regarding allegations including facility disrepair, unsafe environment, unauthorized individuals without fingerprint clearance, and staff stealing money.

The investigation found no evidence that the facility was in disrepair or that staff were stealing money. The allegation that the facility does not provide a safe environment for residents was unsubstantiated based on observations, interviews, and record reviews. No deficiencies were observed during the visit.

The complaint investigation was unsubstantiated. Allegations included facility disrepair, unsafe environment, unauthorized individuals without fingerprint clearance, and staff stealing money. No preponderance of evidence was found to prove the alleged violations occurred.

The visit was an unannounced case management follow-up on an incident report submitted by the facility regarding a resident who ran into the kitchen and threw knives at staff.

The facility was found to have deficiencies for not ensuring knives were kept locked and inaccessible to residents, posing an immediate health and safety risk.

The visit was triggered by an incident report submitted on 6/21/23 concerning a resident who grabbed knives and threw them at kitchen staff on 6/20/23. The complaint was substantiated by observations and interviews.

An unannounced 1 Year Annual Inspection visit was conducted to evaluate compliance with health and safety regulations at the facility.

The inspection found no deficiencies. The physical plant, medication storage, food supplies, safety equipment, and emergency systems were all in good condition and compliant with regulations.

The visit was conducted to follow up on previously given citations and to amend a deficiency from a Type "A" to a Type "B" to reflect a non-immediate safety risk related to medication administration for resident R1.

During the visit, it was confirmed that medication orders for resident R1 were being followed and medications were present. However, a housekeeping cart was found unlocked and unattended in the main hallway with accessible toxins, posing an immediate health and safety risk. The cart was subsequently locked after staff intervention.

The visit occurred to deliver an Order of Exclusion for a staff member and to inform the facility of the immediate exclusion.

The Licensing Program Analysts delivered an Order of Exclusion for a staff member named Maricar Venegas, who is no longer employed at the facility. The facility was informed that Maricar Venegas is not allowed in the facility effective immediately.

Unannounced investigation of a complaint received on 2023-02-24 regarding staff mismanagement of resident medication at Country Club Manor.

The facility failed to follow the doctor's order for resident R1's medication, resulting in the resident being without prescribed medication from July 1, 2020 until February 22, 2023. The medication was discontinued without physician confirmation due to insurance coverage issues, and the replacement medication was delayed. The allegation was substantiated.

The complaint alleging staff mismanaged resident medication was substantiated based on preponderance of evidence standards. The Licensee and Resident Care Coordinator responsible at the time are no longer employed.

An unannounced case management inspection was conducted to discuss and obtain additional information regarding a reported incident involving alleged falsification of employee time sheets by the former administrator.

The inspection found evidence that the former administrator falsified employee time sheets and failed to meet staffing requirements. No deficiencies were issued during the inspection.

An unannounced complaint investigation was conducted regarding an allegation that staff allowed a resident to walk outside without shoes.

The investigation found that the resident did have slippers on while outside, which may not have been proper footwear but did constitute footwear. The complaint was determined to be unfounded.

The complaint alleged that staff allowed a resident to walk outside without shoes. The complaint was found to be unfounded, meaning the allegation was false, could not have happened, and/or was without reasonable basis.

The visit was an unannounced case management follow-up to address a 3-day eviction notice given to a resident without prior written approval from Community Care Licensing.

The licensee was found deficient for issuing a 3-day eviction notice to a resident without obtaining the required prior written approval from the licensing agency, posing a potential health and safety risk to residents in care.

The inspection was an unannounced required 1 year annual inspection conducted to ensure compliance with health and safety regulations.

The facility was found to be clean, odor-free, and in good repair with all safety measures in place including proper water temperature, fire safety equipment, and secure storage of medications and toxins. No deficiencies were cited during the inspection.

An unannounced complaint investigation was conducted regarding allegations that residents were not being provided activities and that food services were inadequate.

The investigation found that due to COVID-19, normal activities were paused but residents were provided with in-room activities such as word puzzles, word searches, reading, and bingo. Regarding food services, the facility provided alternative menu options for residents who did not want to eat the prepared meals. The complaint findings were deemed unsubstantiated due to lack of preponderance of evidence.

The complaint investigation was unsubstantiated. Although the allegations may have happened or be valid, there was not enough evidence to prove the alleged violations did or did not occur.

An unannounced Required 1-Year Visit was conducted to evaluate the facility's compliance and infection control measures.

The facility was observed to have no residents in care and was undergoing remodeling. No deficiencies were cited during the visit, and technical assistance was provided regarding infection control and COVID-19 mitigation.

The visit was an unannounced case management inspection regarding an incident involving Resident 1 and Staff 1, where Resident 1 claimed inappropriate touching by Staff 1 on 12/7/21 and 12/9/21.

The investigation found no direct witnesses to the incident. Staff 1 was placed on temporary leave pending investigation, and a mandatory staff training meeting was scheduled. No deficiencies were cited as a result of the visit.

The complaint involved allegations by Resident 1 of inappropriate touching by Staff 1. The Residential Care Coordinator conducted interviews but found no direct witnesses. Staff 1 was placed on temporary leave and reassigned pending further action.

The visit was an unannounced case management visit to follow up on a delinquent notice regarding an outstanding payment issue charged to Solar Senior Living 2 LLC.

No deficiencies were cited during the visit. The facility provided lien release documents clearing the outstanding payment, and requested documents were noted.

An unannounced complaint investigation was conducted following a complaint received on 2021-11-05 regarding issues such as a resident having no call button and staff not maintaining a comfortable temperature in the facility.

The investigation substantiated that Resident 1's call button was not working, posing a potential threat to resident safety, but found the complaint about facility temperature to be unsubstantiated as temperatures were adequate.

The complaint investigation was substantiated for the allegation that Resident 1 had no working call button. The allegation that staff did not maintain a comfortable temperature was unsubstantiated.

The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 10/07/2021 regarding uncomfortable facility temperature and medication mismanagement.

Based on interviews with residents and staff, and review of pertinent documents, there was no substantial evidence to support or disprove the alleged violations. The complaint findings were deemed unsubstantiated due to lack of physical evidence and witness statements.

The complaint investigation was unsubstantiated as there was no preponderance of evidence to prove the alleged violations occurred. Allegations included staff not maintaining comfortable temperature and mismanaging residents' medication.

The visit was an unannounced follow-up to clear the Plan of Correction (POC) items from a previous visit dated 06/25/2021.

The deficiencies cited during the 06/25/2021 visit, specifically related to water temperature regulation, have been cleared as of this visit on 09/09/2021.

The visit was an unannounced complaint investigation triggered by an allegation of insufficient staff resulting in a resident wandering out of the facility and sustaining an injury.

The investigation substantiated that a 101-year-old resident fell outside in the gated back parking lot without staff supervision, posing an immediate health and safety risk. Another complaint regarding staff restricting residents from sugar food/drink items was found to be unfounded.

The complaint was substantiated regarding insufficient staff supervision leading to a resident fall. The allegation about restricting residents from sugar food/drink items was found to be unfounded.

The inspection was an unannounced complaint investigation visit conducted in response to complaints received on 2021-04-26 regarding facility heater disrepair and food being served cold.

The investigation found the complaint about the facility heater being in disrepair to be unfounded, as the heater was observed to be in working order and the facility temperature was adequate. The complaint about food being served cold was unsubstantiated due to insufficient evidence, with residents reporting food was mostly warm.

The complaint investigation was conducted for two allegations: 1) Facility heater is in disrepair, which was found to be unfounded, and 2) Food is being served cold, which was found to be unsubstantiated due to lack of sufficient evidence.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2021-01-19 alleging that the facility was not administering medications as prescribed, interfering with medical care, and not providing regular showers to a resident.

The investigation substantiated the allegation that the facility failed to administer medications as prescribed, evidenced by over 25 unsigned medication administration records between December 2020 and January 2021. Other allegations regarding interference with medical care and lack of regular showers were found to be unfounded.

The complaint investigation was substantiated for the allegation that the facility was not administering medications as prescribed. The other allegations of interfering with medical care and residents not receiving showers regularly were found to be unfounded.

An unannounced complaint investigation was conducted regarding allegations that facility staff yell at residents.

The investigation found that the allegation was unfounded as the preponderance of evidence standards was not met. Interviews with staff and residents did not support the complaint.

The complaint alleged that facility staff yell at residents. The allegation was found to be unfounded.

The inspection was conducted as a required 1 year annual inspection to evaluate the facility's compliance with health and safety regulations.

The facility was generally clean, odor-free, and in good repair with required furniture and safety equipment. However, water temperatures in two rooms did not meet regulatory standards, posing a health and safety risk.

An unannounced complaint investigation was conducted following a complaint received on 2020-12-29 regarding staff communication of COVID-19 guidelines and misinformation about a resident's dementia status.

The investigation found that staff did communicate COVID-19 outbreak and quarantine guidelines to residents and their responsible parties, and the resident in question was not diagnosed with dementia. Therefore, the allegations were determined to be unsubstantiated.

The complaint alleged that staff did not communicate facility COVID-19 guidelines to a resident and her authorized representative, and that staff were misguided to believe the resident had dementia. The complaint was determined to be unsubstantiated.

The inspection was an unannounced complaint investigation visit triggered by allegations including the facility not providing a refund for overpaid rent and being unable to locate a resident's property.

The allegation regarding the refund of overpaid rent was found to be unfounded as the facility waived the 30-day notice fee and issued the refund after about seven months. The allegation about the missing resident's property was unsubstantiated because the facility could not prove or disprove when the item went missing.

The complaint investigation was based on allegations that the facility did not provide a refund for overpaid rent and was unable to locate a resident's property. The refund allegation was unfounded, and the property allegation was unsubstantiated.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2020-12-24 alleging the facility was denying residents access to phones, interfering with medical care, and restricting resident movements.

The allegation that the facility denied residents access to phones was substantiated due to lack of a phone in a common area and restricted phone use. Allegations regarding interfering with medical care and restricting resident movements were unsubstantiated due to conflicting information and insufficient evidence.

The complaint investigation was substantiated for the allegation of denying access to phones. The allegations of interfering with medical care and restricting resident movements were unsubstantiated.

The inspection was an unannounced complaint investigation visit triggered by allegations that the facility was withholding Personal Protective Equipment (PPE) from staff and requiring COVID-19 symptomatic staff to return to work.

The investigation found that the facility ordered and obtained PPE supplies, including surgical masks, but not N95 masks. Staff interviews revealed conflicting information about whether symptomatic staff were required to return to work. The allegations were determined to be unsubstantiated due to insufficient evidence.

The complaint was unsubstantiated, meaning there was not a preponderance of evidence to prove the alleged violations occurred.

The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility was incorrectly billing the responsible party for rent invoices already paid.

The investigation found the complaint to be substantiated, confirming that the responsible party was incorrectly billed for rent invoices already paid, which is inconsistent with the facility's admission agreement and poses a potential health and safety risk to residents.

The complaint was substantiated based on a preponderance of the evidence standard. The allegation was that the facility incorrectly billed the responsible party for rent invoices already paid.

The visit was an unannounced complaint investigation triggered by allegations received on 04/24/2020 regarding staff mishandling a resident's medication, failure to refill medication in a timely manner, and failure to arrange transportation for a resident following a doctor's visit.

The investigation substantiated the allegation that staff mishandled a resident's medication by administering the wrong dosage and medication not prescribed to the resident. The facility was found to have the medication but the staff member did not locate it properly. The allegations regarding failure to refill medication timely and failure to arrange transportation were found to be unsubstantiated.

The complaint investigation was substantiated for staff mishandling resident medication, specifically administering a like-product medication with incorrect dosage not prescribed to the resident. The allegations that staff did not refill medication timely and did not arrange transportation for the resident were unsubstantiated.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2020-05-18 regarding staff mishandling resident medications.

The allegation that staff mishandled resident medications was substantiated based on interviews, observations, and record review. However, allegations related to personal rights and insufficient staffing were found to be unsubstantiated.

The complaint was substantiated regarding staff mishandling resident medications due to unqualified staff administering medications as a result of short staffing and lack of proper training. Allegations of personal rights violations and insufficient staffing were unsubstantiated.

The inspection was an unannounced complaint investigation visit triggered by an allegation that staff were not qualified to distribute medication.

The investigation substantiated that staff administered medications without completing required training, partly due to short staffing caused by employee call-offs and suspensions. The facility did not ensure qualified assistance was given to residents regarding medication administration.

The complaint alleged staff were not qualified to distribute medication. The allegation was substantiated based on interviews, observations, and record review.

The inspection was an unannounced complaint investigation triggered by an allegation of staff mismanaging resident's medication received on 06/08/2020.

The investigation found the allegation of medication mismanagement substantiated based on interviews, observations, and record review. The facility had experienced staff shortages due to COVID-19 fears, leading to medication not being pre-poured or passed on some days. Deficiencies related to employee training on medication assistance were cited.

The complaint alleging staff mismanaging resident's medication was substantiated. The investigation included interviews, documentation review, and observations. The facility admitted to medication mismanagement incidents on 05/22/2020 and 05/25/2020 due to employee call-offs and suspensions.

The inspection was conducted as an unannounced complaint investigation regarding allegations that the facility was not allowing residents to access common rooms without just cause.

The investigation found that due to a current positive COVID-19 case at the facility, the administrator's actions to restrict access to common rooms were justified. Therefore, the allegation was determined to be unfounded.

The complaint alleged that the facility was not allowing residents to access common rooms without just cause. The allegation was found to be unfounded due to justifiable COVID-19 precautions.

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