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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 090317665
Report Date: 05/01/2024
Date Signed: 05/01/2024 11:49:11 AM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/26/2024 and conducted by Evaluator Lavinia Muscan
COMPLAINT CONTROL NUMBER: 59-AS-20240126155910
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: 36DATE:
05/01/2024
UNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Administrator Bonnie StoneTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff are not fingerprint cleared
Staff do not meet resident toileting needs
Staff do not ensure residents are adequately fed
Staff do not provide daily activities for residents
Staff are retaining residents that require a higher level of care
INVESTIGATION FINDINGS:
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On 5/1/24, Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Administrator Bonnie Stone.

During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

**Report continued on 9099-C**
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia MuscanTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024
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 2
Control Number 59-AS-20240126155910
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 CENTER
FACILITY NUMBER: 090317665
VISIT DATE: 05/01/2024
NARRATIVE
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Staff are not fingerprint cleared
Based on record reviewed and interviews conducted, all staff have fingerprint clearance and therefore the above allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis.
Staff do not meet resident toileting needs
Department conducted record review, staff, and resident interviews to investigate this allegation. Four (4) staff interviews indicated that staff were providing all ADL assistance, including toileting to residents per their needs and service plan. Staff interviews indicated that staff were assisting residents for their toileting needs every 2 hours or as needed. Five (5) resident interviews reflected that their care needs were met by staff and there were no issues to address, therefore the above allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis.
Staff do not ensure residents are adequately fed
Based on record reviewed, interviews, and observation, the department observed plenty of food to feed the residents in care. The department also observed a snack bar that is open for all residents for in-between meals. Five (5) resident interviews indicated that the facility was providing adequate food to them and there were no problems. During department visits on 1/30/24 and 2/7/24, it was observed that facility was providing a variety of food choices to all residents including a daily menu from where residents can choose what they want to eat, therefore the above allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis.
Staff do not provide daily activities for residents
Based on record reviewed, interviews and observation the department observed residents taking part in different activities daily. Five (5) resident interviews indicated that the facility was providing a variety of activities for the residents to take part in. During department visits on 1/30/24 and 2/7/24, it was observed the facility was providing different activities to residents who wish to participate. Additionally, Department observed monthly activity calendar posted in common areas at the facility, therefore the above allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis.
Staff are retaining residents that require a higher level of care
Department conducted record review and staff interviews to investigate this allegation. Record review indicated that facility was providing care to those residents who meet the criteria for Title 22 regulation for RCFE. Four (4) staff interviews indicated that residents care needs are met per their needs and service plan and there were no residents who need higher level of care, therefore the above allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis.
Exit interview was conducted with Administrator and a copy of this report was provided to the facility.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia MuscanTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2