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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 095920119
Report Date: 05/13/2024
Date Signed: 05/15/2024 07:32:36 AM


Document Has Been Signed on 05/15/2024 07:32 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
CCLD Regional Office, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814



FACILITY NAME:GOLD COUNTRY ASSISTED LIVINGFACILITY NUMBER:
095920119
ADMINISTRATOR:STONE, BONNIEFACILITY TYPE:
740
ADDRESS:4301 GOLDEN CENTER DRIVETELEPHONE:
(530) 621-1100
CITY:PLACERVILLESTATE: CAZIP CODE:
95667
CAPACITY:46CENSUS: DATE:
05/13/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:BONNIE STONE, JACK SANOFSKYTIME COMPLETED:
01:18 PM
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Facility Type: RCFE
Application Type: Change of Ownership
Capacity: 46
Census (if any clients in care): 36
COMP II Participants: BONNIE STONE, JACK SANOFSKY
Interview Method: Telephone interview

On May 13, 2024, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed the understanding of the California Code Title 22 Regulations. Signed LIC 809 with copy of photo ID have been obtained.
During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing requirements & Training
4. Restricted/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing readiness
SUPERVISOR'S NAME: Jude De La ConcepcionTELEPHONE: (916) 651-7841
LICENSING EVALUATOR NAME: Bethany HunterTELEPHONE: (916) 651-3571
LICENSING EVALUATOR SIGNATURE:
DATE: 05/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2024
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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