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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 095920119
Report Date: 05/20/2024
Date Signed: 05/20/2024 12:42:15 PM


Document Has Been Signed on 05/20/2024 12:42 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 ASSISTED LIVINGFACILITY NUMBER:
095920119
ADMINISTRATOR:STONE, BONNIEFACILITY TYPE:
740
ADDRESS:4301 GOLDEN CENTER DRIVETELEPHONE:
(530) 621-1100
CITY:PLACERVILLESTATE: CAZIP CODE:
95667
CAPACITY:46CENSUS: 34DATE:
05/20/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator Bonnie StoneTIME COMPLETED:
01:00 PM
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On 5/20/2024 Licensing Program Analyst (LPA) Lavinia Muscan met with Administrator/Applicant, Bonnie Stone, to conduct an unannounced Pre- Licensing visit. This application is a change of ownership. This address is currently licensed as Gold Country Health Center Facility #090317665. Applicant holds a current administrator certificate (#6066896740 with expiration date 7/16/2025). The facility currently has 34 residents. There are three residents on hospice. Three resident on oxygen. There is a fire clearance for 46 non-ambulatory residents at this facility.

LPA toured the facility with Administrator Bonnie Stone. The food supply is within compliance, 2 days of perishable and 7 days’ worth of non-perishable food items. Smoke detectors are operational. Carbon monoxide detectors are functioning. The Fire extinguisher was charged, serviced and functional. Grab bars were present at the toilet and in the shower. All exits were unobstructed. All toxins, medications, and sharps were locked and stored away. The disaster drill is current. The administrator's certificate is current. There is a side gate for emergency access.

During today's pre-licensing inspection, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed resident (5) and staff files (5). All resident files contained the required paperwork. All staff files contained the required paperwork. All staff have current first aid and CPR training. Facility was clean and well organized. Facility is current on fire drills. Staff training contained the required initial training.

Component III for RCFE was completed with Administrator/Applicant Bonnie Stone during today's visit. LPA will forward findings to the Centralized Application Bureau (CAB) that facility met all the pre-licensing components.

Applicant has satisfied all requirements in accordance to Title 22, California Code of Regulations on today's pre-licensing inspection. A copy of this report was provided to the facility. Exit interview conducted.

SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia MuscanTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 05/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2024
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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