095920119-1-21-2026-59-AS-LMUZ-DQKSQT-20260122130516

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 095920119
Report Date: 01/21/2026
Date Signed: 01/21/2026 10:05:29 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
10/24/2025 and conducted by Evaluator Lavinia Muscan

COMPLAINT CONTROL NUMBER: 59-AS-20251024113908

FACILITY NAME:	GOLD COUNTRY ASSISTED LIVING		FACILITY NUMBER:	095920119
ADMINISTRATOR:	STONE, BONNIE		FACILITY TYPE:	740
ADDRESS:	4301 GOLDEN CENTER DRIVE		TELEPHONE:	(530) 621-1100
CITY:	PLACERVILLE	STATE: CA	ZIP CODE:	95667
CAPACITY:	46	CENSUS: 38	DATE:	01/21/2026
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Administrator Kayla Archer		TIME COMPLETED:	10:15 AM

ALLEGATION(S):

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Staff mismanaged residents’ medications.

INVESTIGATION FINDINGS:

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On 01/21/2026, Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Administrator Kayla Archer.

During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows:
Based on documents obtained and statements reviewed for October 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 staff interviews (5) indicated that staff were not aware of any medication errors. 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.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Lavinia Muscan
LICENSING EVALUATOR SIGNATURE:	DATE: 01/21/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2026

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 3

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
10/24/2025 and conducted by Evaluator Lavinia Muscan

COMPLAINT CONTROL NUMBER: 59-AS-20251024113908

FACILITY NAME:	GOLD COUNTRY ASSISTED LIVING		FACILITY NUMBER:	095920119
ADMINISTRATOR:	STONE, BONNIE		FACILITY TYPE:	740
ADDRESS:	4301 GOLDEN CENTER DRIVE		TELEPHONE:	(530) 621-1100
CITY:	PLACERVILLE	STATE: CA	ZIP CODE:	95667
CAPACITY:	46	CENSUS: 38	DATE:	01/21/2026
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Administrator Kayla Archer		TIME COMPLETED:	10:15 AM

ALLEGATION(S):

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9

Staff did not ensure residents received contracted services.
Staff did not maintain accurate records for residents.

INVESTIGATION FINDINGS:

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Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Lavinia Muscan
LICENSING EVALUATOR SIGNATURE:	DATE: 01/21/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 59-AS-20251024113908

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: 01/21/2026

NARRATIVE

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Staff did not ensure residents received contracted services.
Based on documents obtained and statements reviewed, the department determined that residents are receiving all services based on their Admission agreement and needs and service plan. Therefore, the 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 did not maintain accurate records for residents.
Based on documents obtained and statements reviewed, the department determined the Licensee ensured that a complete and current record, including Admission Agreement, Needs and Service plan, Physician’s report etc. was maintained for residents in care. Therefore, the 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: 01/21/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2026

LIC9099 (FAS) - (06/04)

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