342700512-1-23-2023-25-AS-APEZ-CNZTM2-20230213135025

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700512
Report Date: 01/23/2023
Date Signed: 01/23/2023 04:59:55 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/26/2022 and conducted by Evaluator Cassie Yang

COMPLAINT CONTROL NUMBER: 25-AS-20220926082606

FACILITY NAME:	GOLDEN RETREAT SENIOR LIVING 1		FACILITY NUMBER:	342700512
ADMINISTRATOR:	HOLMQUIST, TRAVIS C		FACILITY TYPE:	740
ADDRESS:	3425 PALESTINE LN		TELEPHONE:	(916) 482-5507
CITY:	CARMICHAEL	STATE: CA	ZIP CODE:	95608
CAPACITY:	6	CENSUS: 4	DATE:	01/23/2023
		UNANNOUNCED	TIME BEGAN:	03:35 PM
MET WITH:	Oliver Fule		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Personal Rights

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Cassie Yang arrived at the facility unannounced on January 23, 2023 to deliver complaint finding. LPA met with Administrator, Oliver Fule, and explained the purpose of the visit. Prior to initiating the complaint visit, LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask.

The investigation found on 11/18/2022, it was discovered the complaint was generated on the incorrect facility. Therefore, IB will be closing out this case.

As a result of this investigation, LPA finds allegation to be Unfounded - A finding that a complaint allegation is unfounded means that the allegation was false, could not have happened and/or is without a reasonable basis.

An exit interview was conducted with Administrator and a copy of the report and appeal rights was left at the facility.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie Yang	TELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2023

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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