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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 037001001
Report Date: 11/17/2022
Date Signed: 11/17/2022 04:50:56 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
11/09/2022 and conducted by Evaluator Victoria Brown
COMPLAINT CONTROL NUMBER: 27-AS-20221109113829
FACILITY NAME:GOLD QUARTZ INN RETIREMENT HOMEFACILITY NUMBER:
037001001
ADMINISTRATOR:FLETA HERNDONFACILITY TYPE:
740
ADDRESS:15 BRYSON DRIVETELEPHONE:
(209) 267-9155
CITY:SUTTER CREEKSTATE: CAZIP CODE:
95685
CAPACITY:47CENSUS: 26DATE:
11/17/2022
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Amber Warren, PM SupervisorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Facility is not providing residents transportation to medical appointments.
Facility staff member did not assist resident with a brief change in a timely manner resulting in resident sitting in feces for an extended period of time.
Facility staffing is not sufficient to meet the needs of the residents.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to investigate the above mentioned allegations on 11/17/22 at 12:30p. LPA met with Amber Warren, PM Supervisor and stated the purpose of the visit. LPA interviewed resident #1 (R1) - (R7) and Staff #1 (S1) - (S6).

Regarding allegation, "Facility is not providing residents transportation to medical appointments." LPA toured the facility van with S3 and took pictures of the ramp inside and the step stool. LPA attempted to lift the ramp which was extremely heavy. LPA observed the stool to contain duck tape to hold the legs together. S3 is currently unable to lift the ramp to assist residents onto and off the van which in turn does not allow the residents to be transported. S3 is the only transportation driver for the facility van at this time. The ramp is not broken it is too heavy for S3 to lift due to medical reasons and possibly a second transport staff would be needed to lift the ramp to assist residents on and off the van for appointments. LPA obtained information that the facility is utlizing the van from next door which is not licensed by Community Care Licensing (CCL) to assist, however the lift on that van is broken.
Substantiated
Estimated Days of Completion: 30
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2022
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 4
Control Number 27-AS-20221109113829
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: 11/17/2022
NARRATIVE
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LPA observed in the Plan of Operation submitted to Community Care Licensing (CCL) upon Licensure that the facility under Basic Services Provision or arrangement for transportation to local functions such as church or doctor appointments within a near by radius will be provided. And under Transportation Transportation is provided by several means...and residents special need in the facility van.
Based on interviews, the preponderance of evidence standard has been met.

Regarding allegation, "Facility staff member did not assist resident with a brief change in a timely manner resulting in resident sitting in feces for an extended period of time." LPA conducted interviews of (S1-S6) and (R1) which revealed that residents are not being changed timely for incontinence. This personal rights violation would be residents bedding not being changed with the incontinence care leaving brown spots on the bed and leaving the resident in urine and/or feces for an extended period of time. LPA observed in the Plan of Operation submitted to Community Care Licensing (CCL) upon Licensure that the facility under Basic Health Services facility will provide observation and assistance with personal needs and bedside care needs.
Based on interviews, the preponderance of evidence standard has been met.

Regarding allegation, "Facility staffing is not sufficient to meet the needs of the residents" LPA conducted interviews of (S1-S6) and (R1-R7) which revealed conflicting information. LPA obtained information that the facility is cross training/working staff. In addition, LPA received information that care staff are used to transport food to the independent apartments next door on a daily basis for all meals. There is at this time 26 residents and 1 caregiver to each floor with 1 Medication Technician. Specifically, on days when 1 staff does not work there is only 1 caregiver and MT 1 of which is used to deliver meals to the independent apartments next door during their shift which leaves an insufficient number of staff for the supervision of residents. Based on interviews the facility is in need of additional staffing.
Based on interviews, the preponderance of evidence standard has been met.
Based on interviews and observations, the preponderance of evidence standards has been met; therefore, the above allegation(s) is found to be SUBSTANTIATED. A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 9099D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. The Administrator was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20221109113829
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: 11/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
11/18/2022
Section Cited
CCR
87208(a)(8)
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Plan of Operation
Transportation arrangements for persons served who do not have independent arrangements.
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Licensee shall submit a plan on how to accommodate ambulatory and non ambulatory residents who need transportation for appointments as stated in Plan of Operation. Please fax to (916) 263-4744 by POC due date.
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This requirement is not met as evidenced by:
Observation Staff is unable to utilize the ramp to assist residents onto and off the van while using a wheelchair
Based on interviews, the licensee did not ensure van is properly equipped for the safety of staff and residents This posed an immediate health and safety risk to residents in care.
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Deficiency Dismissed
Type A
11/18/2022
Section Cited
CCR
87625(b)(1-3)
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Managed Incontinence In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following:
Ensuring that residents who can benefit from scheduled toileting are assisted or reminded to go to the bathroom at regular intervals rather than being diapered.
Ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night.
Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.
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Licensee shall submit a plan on conducting an in-service for staff regarding caregiveing procedures and scheduled incontinence care for all residents. Please fax to (916) 263-4744 by POC due date.
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This requirement is not met as evidenced by: Interviews that staff is not assisting residents with incontinence timely Based on interviews, the licensee did not ensure staff is assisting residents with incontinence This posed an immediate 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: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20221109113829
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: 11/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
11/18/2022
Section Cited
CCR
87411(a)
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Personnel Requirements - General
Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.
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Licensee shall submit a plan on how to accommodate their licensed RCFE and the independent apartments next door. Please fax to (916) 263-4744 by POC due date.
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This requirement is not met as evidenced by: Interviews staff is insufficient in numbers to provide care and supervision
Based on interviews, the licensee did not ensure sufficient staffing who are used to asssist independent apartments next door This posed an immediate 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: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4