095920119-1-21-2026-59-AS-LMUZ-DQKSRF-20260122130616

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 095920119
Report Date: 01/21/2026
Date Signed: 01/21/2026 10:06:38 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
11/19/2025 and conducted by Evaluator Lavinia Muscan

COMPLAINT CONTROL NUMBER: 59-AS-20251119082828

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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Licensee does not ensure staff have required training
Staff do not ensure medication is stored in originally received container

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:

**Report continued on 9099-C**

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)

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Control Number 59-AS-20251119082828

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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Licensee does not ensure staff have required training
Based on documents obtained and statement reviewed, the department determined that Licensee does ensure staff have required training. Department reviewed trained records and noted that staff were adequately trained per regulations with topics including medication management, Dementia, resident rights, activities, ADLs, etc. Records show the required training hours. Staff interviewed stated that staff do receive training. Based on information gathered staff are receiving the required training. Department finds allegation to be UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis.

Staff do not ensure medication is stored in originally received container
Based on documents obtained, statement reviewed, and observation of Med carts on October 27, 2025, and November 24, 2026, the department determined that staff do ensure that medications are stored in their originally received containers; 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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