037001001-9-26-2023-27-AS-KHOS-CWJHX8-20231012063444

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 037001001
Report Date: 09/26/2023
Date Signed: 09/26/2023 03:56:41 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
09/20/2023 and conducted by Evaluator Christina Valerio

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20230920142634

FACILITY NAME:	GOLD QUARTZ INN RETIREMENT HOME		FACILITY NUMBER:	037001001
ADMINISTRATOR:	LOREEN HICKMAN		FACILITY TYPE:	740
ADDRESS:	15 BRYSON DRIVE		TELEPHONE:	(209) 267-9155
CITY:	SUTTER CREEK	STATE: CA	ZIP CODE:	95685
CAPACITY:	47	CENSUS: 26	DATE:	09/26/2023
		UNANNOUNCED	TIME BEGAN:	12:50 PM
MET WITH:	Loreen Hickman		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff did not secure resident's wheelchair appropriately in vehicle resulting in the resident tipping over sustaining injuries during a vehicle collision

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to conduct a 10 Day Visit, complaint investigation, and deliver complaint findings. LPA met with Administrator Loreen Hickman, explained the purpose of the visit.

On 05/04/23, LPA Valerio and Licensing Program Manager (LPM) Richardson conducted a case management visit at the facility due to receiving notification of an incident that occured on 04/27/23. During the visit, LPA obtained documentation, interviewed staff, and observed staff preforming their procedures on how to secure a wheelchair in the van. After review of files and staff interviews, the facility was cited California Code of Regulations (CCR), Title 22, Section 87707(a)(2) for not ensuring all staff were properly trained on Van Procedures and Transportation.

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 4

Control Number 27-AS-20230920142634

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

According to the incident report submitted to the Regional Office, on 04/27/23 at 11:15 AM, Resident 1 (R1) was being transported to an appointment with Staff 1 (S1) and Staff 2 (S2). S1 was driving the facility van while S2 was sitting in the back of the van behind R1. S1 made a turn going 5 miles per hour. While turning, R1 fell while still in their wheelchair, landing on the floor and on their right side of their body. S2 assisted by elevating R1's head while on the vehicle floor. S2 performed verbal checks and assisted R1 back into the wheel chair after the fall and secured R1 to continue transportation to R1 appointment. R1 was observed to have a skin tear. S2 performed first aid. R1 was on the way to the doctor's office. R1's responsible party and primary care provider was notified. The doctor's office re-bandaged R1's injury and R1 will be provided home health follow up care.

On 09/25/23, LPA reviewed a Traffic Crash Report from the Department of California Highway Patrol. According to the summary/case report, Staff 1 was driving the facility van, southbound on SR-49 at the intersection with SR-88 stopped at the stop limit line. As the traffic signal turning green, Staff 1 began to make the left turn and accelerated into the intersection at the stated speed of approximately 10-15 miles per house. At that speed, the wheelchair began to overturn to the right with [R1] still in the chair. Due to S1's unsafe turning movement, [R1] wheelchair fully overturned to the right allowing both [R1] and the wheelchair to fall, both striking the floor of the vehicle. Following the crash, [S1] and [S2] assisted [R1] back to an upright position, provided minor first aid, and continued to their original destination.

According to an interview with the administrator, Administrator Loreen confirmed that S1 and S2 did not report the incident to CHP as they were already heading to R1's doctor appointment. Facility records confirm that S1 was not the individual to secure the wheelchair. S2 and S3 assisted R1 in the van. S1 and S2 did not double check to make sure the wheelchair was locked into a secure position.

LPA reviewed pictures submitted by an outside agency of R1. Pictured is only the elbow to the middle forearm. The entire elbow and forearm region had evidence of bruising. This is evident by black, red, and purple colored skin. There is a skin tear roughly about 1 and 1/2 inch in diameter. Where there is a skin tear, it is bright red and black blood clots.

Continues on LIC 9099 - C, Page 3...

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 4

Control Number 27-AS-20230920142634

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 - C

Another picture was provided to the RO on 09/20/23. The picture shows Resident 1 drinking a drink while sitting in a chair. The resident has bruises on the face located under the eye, in the middle of the cheek, and below the ear. The resident also has a large bruise starting from proximal area of the forearm to the distal area of the forearm. The resident is show to have a large bandage wrapped around her forearm.

Based on interviews and records review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.

Per California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached LIC 9099 - D. Failure to correct deficiencies may result in civil penalties. Appeal Rights Provided. An exit interview was held, and a copy of the report was provided.

Licensee was informed that an immediate civil penalty of $500 is issued in addition to citation due to injury related to violation of Section 1569.312(e). At the time of the complaint visit, the issuance of a Civil Penalty was still being determined and the licensee was informed that a civil penalty might be assessed based on Health and Safety Code § 1569.49(f).

This report was amended to reflect the assessment of the civil penalty and possible civil penalty might be assessed based on Health and Safety Code § 1569.49(f).

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: 3 of 4

Control Number 27-AS-20230920142634

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)
Deficiency Dismissed Type B 10/10/2023 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	87468.2 Additional Personal Rights of Residents (a)In addition to.. Section 87468.1,.. residents...shall have all of the following: (4)To care, supervision, and services that meet their individual needs ...delivered by staff that are sufficient in numbers, qualifications, and competency...	1 2 3 4 5 6 7	Licensee stated they conducted and completed training on Transportation Procedures during May and June of 2023. Licensee stated facility staff will continue refresher training every 6 month/as needed. By the POC due date, Licensee will submit a statement of their training plan/procedures.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on records review and interviews, the licensee neglected to ensure R1's needs were met by staff, which resulted in R1 sustaining injuries. This poses a potential health and personal rights risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
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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)

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