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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 090317665
Report Date: 07/30/2021
Date Signed: 07/30/2021 02:46:41 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:GOLD COUNTRY HEALTH CENTERFACILITY NUMBER:
090317665
ADMINISTRATOR:SANDRA HASKINSFACILITY TYPE:
740
ADDRESS:4301 GOLDEN CENTER DR.TELEPHONE:
(530) 621-1100
CITY:PLACERVILLESTATE: CAZIP CODE:
95667
CAPACITY:46CENSUS: 31DATE:
07/30/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:MaryAnn Cook, Assisted Living DirectorTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Wolter arrived at the facility unannounced on 07/30/2021 to conduct a Required-1 Year Inspection utilizing the infection control domain, LPA met with administrator MaryAnn Cook and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and contacted administrator and completed a facility risk assessment.

LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA was screened by facility upon entry.

LPA and administrator toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, brief inspection of six (6) resident bedrooms, resident bathrooms, kitchen area, activity room, and outdoor patio. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and administrator completed the infection control domain together and facility was found to be in substantial compliance at this time.

No deficiencies are being cited as a result of todays inspection.
Exit interview conducted and copy of report to be emailed to administrator.

Administrator to send in updated copy of LIC 808 - Mitigation Plan, LIC 308 - Designation of Facility Responsibility and LIC 500 - Personnel Report to Community Care Licensing by 08/06/2021. LPA obtained copy of facility's current liability insurance during inspection.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Danyle WolterTELEPHONE: (916) 708-5307
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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