Inspection Reports for
Country Club Manor

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.

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 for failure to notify the responsible party of an incident, lack of supervision resulting in multiple assaults between residents, and failure to protect a resident from physical attacks. The allegation that staff were not trained to care for residents with dementia was unsubstantiated.

The investigation substantiated allegations 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 a protective plan. However, the allegation that staff were not trained to care for residents with dementia was unsubstantiated. Deficiencies were cited related to reporting requirements, personal rights, and care and supervision.

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.

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 resident R2 stabbed resident R1 with a fork. The complaint investigation found incomplete incident reporting and failure to notify responsible parties as required by regulations.

The facility failed to notify the responsible party and primary care physician of resident R1 after the incident, despite documentation indicating otherwise. Additionally, the facility had an overdue annual exam for resident R2. Deficiencies were cited related to false claims in documentation and failure to conduct timely reappraisals.

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.

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 evidence that residents were disturbed by frequent loud calls for help due to inadequate emergency pull chord accessibility for a visually impaired resident.

The investigation found that one resident with vision impairment was unable to effectively use the single centrally located emergency pull chord, resulting in frequent loud calls for help by two roommates up to 8 times in 24 hours. This behavior disturbed nearby residents, making them uncomfortable and interfering with their daily activities and sleep. The complaint was substantiated.

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 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 addressed allegations including unsecured trash bin lids, financial abuse, unqualified medication administration, inadequate resident clothing, insufficient administrator presence, and failure to ensure residents ate meals. The allegations regarding administrator presence and meal provision were substantiated, while the others were unsubstantiated.

The investigation found four allegations unsubstantiated, including unsecured trash bin lids, financial abuse of residents, unqualified staff administering medications, and residents not being 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 as documented in meal logs.

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 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.

The visit was triggered by a complaint/incident report concerning a resident's unsafe behavior involving knives. The deficiency was substantiated as the facility failed to keep knives locked and inaccessible.

The facility was found to have not ensured that knives were kept locked and inaccessible to residents, posing an immediate health and safety risk. Deficiencies were cited under California Code of Regulations, Title 22, and California Health and Safety Code.

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.

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.

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.

During the visit, it was confirmed that medication orders for R1 were being followed properly. However, an unlocked housekeeping cart containing toxins was observed, posing an immediate health and safety risk. The cart was immediately locked by staff.

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.

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 was substantiated based on the preponderance of evidence standard. The allegation involved staff mismanagement of resident medication, specifically failure to follow the doctor's order for R1's medication.

The investigation found that the facility did not 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 allegation was substantiated and deficiencies were cited related to medication administration.

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 licensee was found deficient for issuing a 3-day eviction notice without obtaining prior written approval from the licensing agency, which poses a potential health and safety risk to residents. The eviction notice was rescinded the same day after the administrator learned the proper procedures.

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 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 a resident had no call button, while the allegation that staff did not maintain a comfortable temperature was unsubstantiated.

The investigation substantiated that Resident 1's call button was not working and was subsequently fixed during the visit. The allegation regarding uncomfortable facility temperature was found to be unsubstantiated based on observations and resident interviews.

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 deficiencies initially cited during the 06/25/2021 visit were cleared. Specifically, the facility administrator adjusted the water temperature from 130 to below 120 degrees, and the facility will conduct water temperature logs for two weeks to ensure compliance.

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

The allegation of insufficient staff leading to a resident wandering and falling was substantiated, with evidence showing the resident was unsupervised during the fall. The allegation regarding restriction of sugar food/drink items was found to be unfounded, with residents having access to desserts and snacks including sugar-free options.

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.

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 failure to administer medications as prescribed. Other allegations were found to be unfounded. The substantiated deficiency was cited per Title 22 Regulations, Division 6.

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 facility was generally clean, odor-free, and in good repair with required furniture and lighting. However, a deficiency was found in water temperature regulation, with temperatures recorded outside the required 105-120 degrees Fahrenheit range, posing a health and safety risk.

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.

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 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 that the facility denied access to phones. The allegations regarding interfering with medical care and restricting resident movements were unsubstantiated.

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

The complaint investigation was substantiated for allegations including staff not properly trained, failure to safeguard residents' belongings, violation of residents' personal rights, cleaning supplies not locked up, failure to communicate residents' change in condition, and administrator qualifications. The allegation of insufficient staffing was unsubstantiated.

The investigation substantiated multiple allegations including improper medication administration and documentation, incomplete resident personal property records, failure to screen visitors during the pandemic, unlocked cleaning supplies accessible to residents, failure to communicate changes in resident condition, and inadequate administrator qualifications. One allegation regarding insufficient staffing was unsubstantiated.

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

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 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 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.