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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 090317665
Report Date: 02/07/2024
Date Signed: 02/07/2024 01:15:10 PM


Document Has Been Signed on 02/07/2024 01:15 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 35DATE:
02/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Administrator, Bonnie StoneTIME COMPLETED:
01:30 PM
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Licensing Program Analysts (LPAs) Talwinder Bains and Lavinia Muscan arrived unannounced to conduct the annual inspection. LPAs met with Administrator Bonnie Stone upon arrival. Currently there are 35 residents of which 2 residents are receiving hospice care.

LPAs toured facility with administrator to ensure health and safety of residents in care. LPAs toured resident rooms, medication room, staff area, bathrooms, kitchen, common living spaces, outdoor spaces, and activity areas. In the areas toured no immediate health, safety, or personal rights violations were observed. There is a locked storage for medications and toxins. Food supply is adequate for 2-day perishable and 7-day nonperishable. LPAs observed an adequate amount of linens and found the first aid kit to be complete. Facility has fire extinguishers which were ready for emergency use. Inside temperature was 75 degree F. Water temperature was measured at 113 degree F. Facility was clean and well organized. Facility is current on fire drills. All required postings were observed. LPA observed smoke detectors and carbon monoxide detector at the care home are operational.

LPAs reviewed 5 residents files and 5 staff files. LPAs reviewed 5 residents medications comparing with current physician orders and found no errors. A review of staff records indicates that all facility staff has received criminal record clearances and/or are associated to this facility. Staff records reviewed indicated training completed. LPAs observed that all care staff had updated CPR and first aid certificates.
No deficiencies were observed or cited today per CCR ,Title 22 Regulations.
Exit interview conducted and copy of the report provided.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2024
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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