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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 090317665
Report Date: 01/30/2023
Date Signed: 01/30/2023 11:04:48 AM


Document Has Been Signed on 01/30/2023 11:04 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:GOLD COUNTRY HEALTH CENTERFACILITY NUMBER:
090317665
ADMINISTRATOR:MARY ANN COOKFACILITY TYPE:
740
ADDRESS:4301 GOLDEN CENTER DR.TELEPHONE:
(530) 621-1100
CITY:PLACERVILLESTATE: CAZIP CODE:
95667
CAPACITY:46CENSUS: 25DATE:
01/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator, Bailie FigleyTIME COMPLETED:
11:20 AM
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On 01/30/2023 Licensing Program Analyst (LPA) Lavinia Muscan, arrived at the facility unannounced to conduct an annual visit using the infection control tool visit. LPA met with Facility Administrator, Bailie Figley and explained the purpose of the visit. Prior to initiating the visit, 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. LPA ensured she used hand sanitizer shortly before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPA was screened by Front Desk.

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 five (5) resident bedrooms, resident bathrooms, dining 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. Facility has 25 residents 3 of which are on hospice.

No deficiencies are being cited as a result of todays inspection.

Exit interview conducted and copy of report left at the facility.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia MuscanTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2023
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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