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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 037001001
Report Date: 09/26/2023
Date Signed: 09/26/2023 03:43:37 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
08/16/2023 and conducted by Evaluator Christina Valerio
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230816155055
FACILITY NAME:GOLD QUARTZ INN RETIREMENT HOMEFACILITY NUMBER:
037001001
ADMINISTRATOR:LOREEN HICKMANFACILITY TYPE:
740
ADDRESS:15 BRYSON DRIVETELEPHONE:
(209) 267-9155
CITY:SUTTER CREEKSTATE: CAZIP CODE:
95685
CAPACITY:47CENSUS: 26DATE:
09/26/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Loreen HickmanTIME COMPLETED:
12:20 PM
ALLEGATION(S):
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Facility did not provide responsible party with former resident's records.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to deliver complaint investigation findings. LPA met with Administrator Loreen Hickman, and explained the purpose of the visit.

LPA Valerio conducted the investigation, which consisted of interviews and record reviews. The Department has determined the following as it relates to the above aforementioned allegation.

According to facility records, Resident 1 (R1) was admitted to the facility in late months of year 2022. R1 was involved in an accident in April of 2023. For reference, please see case management visit dated 05/04/23. On 07/22/23, R1 passed away at the facility. According to Records Review, R1's had a District Power of Attorney (POA) on file. On 08/11/2023, POA/Responsible Party for R1 requested records from Gold Quartz Inn Retirement Home.

Continues on LIC 9099 - C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023
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 3
Control Number 27-AS-20230816155055
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: 09/26/2023
NARRATIVE
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Continued from LIC 9099
POA/RP requested a full and complete copy of R1's resident and business office files. On 08/14/23, Executive Managing Director, Ronald Regan, responded to R1's POA/RP. Ronald's response included the following: "The reference request for designated records from GQI, which is not a health care provider.... Therefore, your request for blanket resident information is denied since the GQI has no clear legal requirement for RCFE's to release records of a deceased resident. Cal.Code Regs Tit.22 ยง 87868 states that the admission agreement between the resident and the facility is automatically terminated by the resident's death, and that no liability or debt accrues after that date. This regulation could be interpreted to mean that [R1] does not have authority to seek copies of documents after the resident's death, as the agreement between the resident and the facility has ended. Based upon the foregoing, GQI may elect to not provide records. However, in an effort to settle the matter, GQI will provide resident payment records and relevant resident care file documents. A designed list of records will be provided on upon your agreement. The list of documents will include the number of pages for the response which will require a payment of $0.25/page of copies that can be emailed to your attention."

LPA Valerio interviewed staff on 08/23/23. According to an interview with Administrator Loreen, Administrator Loreen stated that if anyone were to request records from staff, the staff will inform Loreen and she would take care of the request. Administrator Loreen stated if she is not available to preform the task, Fleta Herndon, may be available. According to an interview with Licensee Ronald Regan, Licensee Ronald is aware that R1 requested documents; however, he wants the POA/RP to request the documents in the right way. Licensee stated he would gladly send the documents if properly requested. According to an interview with the POA/RP, they have not received requested documents as of 09/25/2023.

According to Health and Safety Code Section 1569.269, A resident of a RCFE has the right "To confidential treatment of their records and personal information and to approve their release, except as authorized by law." Per Title 22 regulations, 87506, "the licensee...shall reveal or make available confidential information only upon the resident's written consent or that of his designated representative and Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident.
Per California Code of Regulations (CCR) Title 22, deficiencies are being cited on the attached LIC 809 -D. Failure to correct deficiencies may result in civil penalties. Appeal Rights Provided. An exit interview was held, a copy of the report was provided to Administrator Loreen Hickman.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20230816155055
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: 09/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
10/10/2023
Section Cited
CCR
87405(d)(2)
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87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7)... (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement was not met as evidenced by:
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The Licensee shall provide LPA Valerio a written statement acknowledging review of Health and Safety Code and Title 22 regulations and the facilities plan to ensure the POA/RP receives all documents requested by POC due date.
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Based on records review and interviews, R1's POA/RP records request has not been completed, therefore, the licensee and administrator did not conform to applicable laws, rules, and regulations. This poses a potential health, safety, and personal rights 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: 09/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3