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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 037001001
Report Date: 10/20/2022
Date Signed: 10/20/2022 04:46:45 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/20/2022 and conducted by Evaluator Christina Valerio
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220720142919
FACILITY NAME:GOLD QUARTZ INN RETIREMENT HOMEFACILITY NUMBER:
037001001
ADMINISTRATOR:MACHELLEE ALLISONFACILITY TYPE:
740
ADDRESS:15 BRYSON DRIVETELEPHONE:
(209) 267-9155
CITY:SUTTER CREEKSTATE: CAZIP CODE:
95685
CAPACITY:47CENSUS: 23DATE:
10/20/2022
UNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Facility Staff TIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Facility did not ensure medication destruction record is maintained
Facility did not provide supervision of residents narcotic medication
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to deliver complaint investigation findings. LPA met with facility staff, and explained the purpose of the visit. The department has concluded the following as it relates to the above mentioned allegations. The individual designated to sign was medication technician lead, Brandee Smith.

On 06/09/2022, the department received an incident report from the facility stating it was discovered on 06/05/2022 that narcotic medications (3 pills) were found to be missing from the facility. On the day the pills were discovered to be missing, 3 staff were called to confirm the medication count. According to interviews, staff stated that they do not know where the medications went or if anyone had taken the medications. Staff statement reveal that not all shifts completed a medication count for the narcotic medications. Another staff statement revealed that the facility pre-pours medication for the oncoming shift so staff are unable to attest to which medication was poured.
Continues on LIC 9099 - C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022
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 6
Control Number 27-AS-20220720142919
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/20/2022
NARRATIVE
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Continued from LIC 9099

On 07/07/2022, the department received an incident report from the facility stating it was discovered on 06/30/2022 that narcotic medication (entire bottle) were found to be missing from the facility. After an internal investigation, facility records reveal that narcotic medication sheet was deleted from the facility excel system. This document would be able to show the narcotic count for the pill bottle.

The facility admitted that the medications and medication document were not found. Since the incident, the facility implemented a triple check system for narcotic medications and had medication staff undergo additional training through Relias.

Based on interviews 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: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/20/2022 and conducted by Evaluator Christina Valerio
COMPLAINT CONTROL NUMBER: 27-AS-20220720142919

FACILITY NAME:GOLD QUARTZ INN RETIREMENT HOMEFACILITY NUMBER:
037001001
ADMINISTRATOR:MACHELLEE ALLISONFACILITY TYPE:
740
ADDRESS:15 BRYSON DRIVETELEPHONE:
(209) 267-9155
CITY:SUTTER CREEKSTATE: CAZIP CODE:
95685
CAPACITY:47CENSUS: DATE:
10/20/2022
UNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Facility Staff TIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility did not follow reporting requirements
INVESTIGATION FINDINGS:
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3
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5
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13
Licensing Program Analyst (LPA) Christina Valerio arrived unannouced to deliver complaint investigation findings. LPA met with facility staff, and explained the purpose of the visit. The department has concluded the following as it relates to the above mentioned allegations. The individual designated to sign was medication technician lead, Brandee Smith.

Based on record review, the department received unusual incident reports (SIR)for both incidents within 7 days, which meets Title 22 regulations. For the incident that occured on 06/05/2022, the department received an SIR on 06/09/2022. For the incident that occured on 06/30/2022, the department receievd an SIR on 07/07/2022.

Based on records review, the aforementioned allegation is unfounded and the allegation false. Per California Code of Regulations (Title 22, Division 6, Chapter 8), no defeciences are being cited. An exit interview was conducted, and a copy of the report left at the facility.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 27-AS-20220720142919
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/21/2022
Section Cited
CCR
87465(e)
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87465 Incidental Medical and Dental Care (e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication.. This requirement was not met as evidenced by:
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Licensee stated a new system will be implemented by POC due date. The licensee will save back up files on a USB drives at the start of each month. Licensee to send proof of medication back up sheets to LPA via fax.
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Based on records review and interview, 1 resident medication records were missing from the facility,which poses a potential health and safety risk to persons in care.
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Type B
11/21/2022
Section Cited
CCR
87465(h)(2)
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87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place...This requirement was not met as evidenced by:
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Licensee stated they have implemented a triple check system. Licensee to send copies of count sheet for October and November to LPA by POC due date.
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Based on record review and interviews, the facility did not ensure medication for resident 1 and resident 2 were kept safe and locked away, which caused the medications to come up missing. This poses 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.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6