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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 10:52:12 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
01/09/2025 and conducted by Evaluator Lavinia Muscan
COMPLAINT CONTROL NUMBER: 59-AS-20250109115622
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):
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Staff does not ensure facility is kept free of pests
INVESTIGATION FINDINGS:
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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: 1 of 2
Control Number 59-AS-20250109115622
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 facility is kept free of pests
Based on documents obtained and statements reviewed, the department determined that there was insufficient evidence that the facility is not kept free of pests. The facility representative stated that the pest control company comes in monthly, and more often as needed. Department reviewed Pest Control dates for the past 6 months on 06/25/2024, 07/18/2024, 08/02/2024, 09/10/2024, 10/22/2024, 11/26/2024, 12/03/2025, 01/03/2025, 01/07/2025 and 01/14/2025. It was stated that the Pest Control company just visited the facility over a week ago and sprayed the exterior and interior of the building. The pest control company is continuing to monitor any pest activity. Five (5) staff and five (5) residents were interviewed and stated they have not seen any pests at the facility. During 01/13/2025 and 01/29/2025 visits, the facility was toured and a copy of receipts from the pest control company was provided. 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 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 2