037001001-1-26-2023-27-AS-CVAO-CNFVL4-20230126153118

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 037001001
Report Date: 01/26/2023
Date Signed: 01/26/2023 03:34:25 PM

Document Has Been Signed on 01/26/2023 03:34 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	GOLD QUARTZ INN RETIREMENT HOME		FACILITY NUMBER:	037001001
ADMINISTRATOR:	MACHELLEE ALLISON		FACILITY TYPE:	740
ADDRESS:	15 BRYSON DRIVE		TELEPHONE:	(209) 267-9155
CITY:	SUTTER CREEK	STATE: CA	ZIP CODE:	95685
CAPACITY: 47		CENSUS: 26	DATE:	01/26/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Facility Staff		TIME COMPLETED:	03:45 PM

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	Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct an annual visit. LPA met with facility staff, and explained the purpose of the visit. Upon arrival, LPA noticed construction work in the front entrance of the building. LPA took pictures for reference. The facility is a two story building. In order to enter the facility, a person needs to walk across a bridge walkway. According to staff, the facility started working on the new walkway a few weeks ago. The new and temporary ramp was installed this week. LPA was not made aware of the repairs. LPA requested the building permit. Licensee Ron R. came to the facility around noon and gave LPA the building permits and construction blue print. A technical advisory was given regarding notifying CCL of any repairs or modification done to the facility. Title 87305 Alterations to Existing Building or New Facilities was discussed with Licensee and Executive Director (ED) Fleta Herndon. LPA toured the facility to ensure compliance of title 22 regulations. LPA toured the facility with facility staff. Hot water was measured at 108.7*F in two bathrooms. The facility common areas, including the activity room, dinning hall, day room, and hallways, were observed to be organized and free from debris. The elevator inspection is up to date. Fire extinguishers are up to date and fully charged. After the tour, LPA was met by Licensee Ron and ED Fleta. LPA discussed findings of the tour with ED and Licensee. The ED designated the lead staff on shift to sign off on the report. During the tour, LPA observed room 113. This is a empty resident room on the bottom floor. LPA observed construction items, bed frames, unused mattresses, and other tool items in the room. LPA heard voices in the bathroom. According to interviews, this room is utilized by staff to give showers to residents due to the walk in shower. Licensee was informed of the situation and had hazardous items removed from the room into another vacant room. Continues on LIC 809 - C... Page 1 of 3

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: GOLD QUARTZ INN RETIREMENT HOME	FACILITY NUMBER: 037001001
	VISIT DATE: 01/26/2023

NARRATIVE

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Continued from LIC 809

LPA was at the facility for majority of the day. During this time, there were no planned activities for the residents. According to staff, today is the activities director day off. LPA observed a staff member telling a resident there were no activities for the day.

LPA requested the following copies: LIC 500, LIC 308, Liability Insurance, LIC 90999 - Current Facility sketch with current emergency exits, LIC 610E Current Disaster Plan

Per California Code of Regulations (CCR) - Title 22, Division 6, Chapter 8, deficiencies are being cited. Appeal rights were provided. An exit interview was held with staff, and a copy of the report provided. LPA to send copies of the report to ED Fleta Herndon and Assistant Administrator Loreen Hickman.

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SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023

LIC809 (FAS) - (06/04)

Page: 2 of 5

Document Has Been Signed on 01/26/2023 03:34 PM - It Cannot Be Edited

Created By: Christina Valerio On 01/26/2023 at 03:08 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: GOLD QUARTZ INN RETIREMENT HOME	FACILITY NUMBER: 037001001
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in room 113. This room was being utilized by construction and tool items along with floor staff showering residents in the walk-in bathroom, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/27/2023
	Plan of Correction
1 2 3 4	Licensee had facility staff removed the hazardous and unused items to another vacant room that is not being used by residents or staff. LPA observed the room to be clear from storage items at the end of the visit.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 01/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 01/26/2023 03:34 PM - It Cannot Be Edited

Created By: Christina Valerio On 01/26/2023 at 03:08 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: GOLD QUARTZ INN RETIREMENT HOME	FACILITY NUMBER: 037001001
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87219(a)

Planned Activities

(a) Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities. The activities made available shall include: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interviews, the licensee did not ensure activities were made available to residents, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/23/2023
	Plan of Correction
1 2 3 4	Licensee to send a plan to ensure activities are being offered every day. Licensee to send proof that there is a designated person assigned to conduct planned activities every day of the week.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 01/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023

LIC809 (FAS) - (06/04)

Page: 4 of 5