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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700512
Report Date: 06/09/2023
Date Signed: 06/09/2023 12:17:41 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/28/2022 and conducted by Evaluator Cassie Yang
COMPLAINT CONTROL NUMBER: 25-AS-20221128125842
FACILITY NAME:GOLDEN RETREAT SENIOR LIVING 1FACILITY NUMBER:
342700512
ADMINISTRATOR:HOLMQUIST, TRAVIS CFACILITY TYPE:
740
ADDRESS:3425 PALESTINE LNTELEPHONE:
(916) 482-5507
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: DATE:
06/09/2023
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Oliver FuleTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Staff did not keep the facility free of roaches
Staff did not keep the facility clean or sanitary
INVESTIGATION FINDINGS:
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On 06/09/2023, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility and met with Administrator, Oliver Fule, to deliver findings into the allegation listed above. LPA explained the purpose of the visit. Additionally, LPA wore a surgical mask to ensure the health and saefty of clients in care.

During the investigation, LPA conducted interviews and records review for the allegations cited above.

The results of the investigation are as follows:


** Report continued on 9099-C **
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2023
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 25-AS-20221128125842
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME: GOLDEN RETREAT SENIOR LIVING 1
FACILITY NUMBER: 342700512
VISIT DATE: 06/09/2023
NARRATIVE
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Continued from LIC 9099...

Allegation: Staff did not keep the facility free of roaches

The Department conducted record review and interviews to investigate this allegation. Interview conducted with Admin indicated that facility has a monthly service with All in One Pest Control as an infestation preventative. During interview conducted with R1 indicated that R1 does not have any concerns of roaches at the facility as R1 has hardly seen any present at the facility. During record review revealed that facility has been conducting outdoor treatments for pest, LPA observed a copy of October 2022 invoice.

Allegation: Staff did not keep the facility clean or sanitary

The Department conducted interviews to investigate this allegation. During interview conducted with R1 indicated that R1 does not have concerns of the facility being unsanitary. R1 stated to LPA "they help me with what I need and makes sure the place is clean." During the time of the investigation, LPA conducted an inspection of the facility and found it be free of trash and/or waste.

Based on interviews conducted, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation 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 with Admin, a copy of the report and appeal rights was provided.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2