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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 095920119
Report Date: 02/19/2025
Date Signed: 02/19/2025 10:53:51 AM

Unsubstantiated


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
12/16/2024 and conducted by Evaluator Lavinia Muscan
COMPLAINT CONTROL NUMBER: 59-AS-20241216144601
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: 39DATE:
02/19/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Director of Assisted Living Kayla ArcherTIME COMPLETED:
11:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff does not ensure resident medications are properly managed
Staff does not ensure medications no longer in use are properly discarded
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 2/19/25, Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Director of Assisted Living Kayla Archer.

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**
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Lavinia Muscan
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025
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 4
Control Number 59-AS-20241216144601
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 ASSISTED LIVING
FACILITY NUMBER: 095920119
VISIT DATE: 02/19/2025
NARRATIVE
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Staff does not ensure resident medications are properly managed
Staff does not ensure medications no longer in use are properly discarded
Based on documents obtained and statements reviewed for January 2025, the department determined that there was insufficient evidence that any medication errors have occurred. Documents obtained show that all current medications were administered and logged correctly for residents per their doctor’s orders. Five (5) staff interviews indicated that staff were not aware of any medication errors. Five (5) resident interviews expressed no concerns with medication management. Based upon the information obtained during investigation, the above allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted. Report left with facility.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Lavinia Muscan
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
12/16/2024 and conducted by Evaluator Lavinia Muscan
COMPLAINT CONTROL NUMBER: 59-AS-20241216144601

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: 39DATE:
02/19/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Director of Assisted Living Kayla ArcherTIME COMPLETED:
11:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Licensee is operating the facility beyond its scope of limitations
Staff does not ensure residents records are properly maintained
Licensee does not ensure facility has adequate night supervision with a staff on call and within 10 minutes
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 2/19/25, Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Director of Assisted Living Kayla Archer.

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:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Lavinia Muscan
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 59-AS-20241216144601
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 ASSISTED LIVING
FACILITY NUMBER: 095920119
VISIT DATE: 02/19/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Licensee is operating the facility beyond its scope of limitations
Based on documents obtained and statements reviewed, the department determined that there was insufficient evidence that the facility is operating outside its scope of limitations. Residents are assessed based on change of care, and those that need to be transferred to a skilled facility are transferred if their care needs cannot be met at the facility per RCFE regulations. The facility assists residents that need a higher level of memory care for appropriate placement. Therefore, no regulation has been violated at this time. 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 does not ensure residents records are properly maintained
Based on documents obtained and statements reviewed, the department determined that there was insufficient evidence that facility records were not maintained properly. Department record review found that all records required, in Title 22 87506, were present during record review of resident files. Therefore, no regulation has been violated at this time. 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.



Licensee does not ensure facility has adequate night supervision with a staff on call and within 10 minutes
Based on interviews and record reviewed, it was determined that there are 2-3 staff members scheduled to work the NOC shift with at least 2 people on-call within 10 mins away from the facility. The regulations governing night supervision, 87451 (a)(2) states: "In facilities caring for sixteen (16) to one hundred (100) residents at least one employee shall be on duty on the premises, and awake. Another employee shall be on call, and capable of responding within ten minutes." Therefore, no regulation has been violated at this time. 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 conducted. Report left with facility.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Lavinia Muscan
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4