342700512-9-20-2023-59-AS-LMUZ-CVVV6E-20230921160927

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700512
Report Date: 09/20/2023
Date Signed: 09/20/2023 12:23:54 PM

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
05/15/2023 and conducted by Evaluator Cassie Yang

COMPLAINT CONTROL NUMBER: 59-AS-20230515085002

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: 6	DATE:	09/20/2023
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Oliver Fule		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Staff do not provide adequate food service.
Staff do not provide resident with activities.
Staff interferes with resident's mail delivery.
Staff do not take resident to medical appointments.

INVESTIGATION FINDINGS:

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On 9/20/2023, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to deliver the finding for the allegations cited above. LPA met with Administrator, Oliver Fule, and explained the purpose of the visit.
LPA was informed there may be a possible infectious inflection at the facility. LPA vacated the premises and completed the report in the exterior of the facility.

During the course of this investigation, the Department conducted extensive interviews regarding to the allegation cited above.

Results are as follow, please continue report on LIC 9099-C(1)...

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: 09/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023

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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Control Number 59-AS-20230515085002

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: GOLDEN RETREAT SENIOR LIVING 1	FACILITY NUMBER: 342700512
	VISIT DATE: 09/20/2023

NARRATIVE

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LIC 9099-C (1)...

Allegation: Staff do not provide adequate food service.
Based on interviews, record review and observation, it revealed that facility provides residents in care with adequate food services. Interview conducted with R1 revealed that R1 has no complaints with the food service at the facility. Interview conducted with R2 revealed that R2 has a food allergy that facility is in compliance to. R2 stated facility is "very flexible" with R2's dietary needs. Based on observation, LPA observed the facility to have 2+ days of perishable and 7+ days of non-perishable foods. Based on the file review on the facility menu, it revealed facility is providing residents in care with three meals a day with additional snacks available.

Allegation: Staff do not provide resident with activities.
Based on interviews conducted, it revealed the facility provides residents in care with activities such as puzzles, bingos, crosswords on Sac Bee. Based on interview conducted revealed that walks are available for residents in the backyard as the street in the front of the facility is a busy street. Based on interview with R1 revealed R1 likes to just watch television and is able to do so. Based on interview with R2 revealed R2 would like to do group walks but is content with walking alone.

Allegation: Staff interferes with resident's mail delivery.
Based on interview conducted with Administrator revealed that some residents in care does not get mails to the facility as it is "automatically" mailed to their family member and/or conservator. Interview with Administrator further revealed that Administrator is the one who retrieves mails from the mailbox and personally delivers to each resident in care. Based on interview conducted revealed that R1 does not have any issues with receiving mails at the facility. Based on interview conducted with R2 revealed that R2 does not get much mails to the facility.

Please continue on LIC 9099-C2...

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie Yang	TELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20230515085002

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: GOLDEN RETREAT SENIOR LIVING 1	FACILITY NUMBER: 342700512
	VISIT DATE: 09/20/2023

NARRATIVE

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LIC 9099-C (2)...

Allegation: Staff do not take resident to medical appointments.
Based on interview conducted revealed that residents' family members are the ones to take residents to appointments. Interview conducted with Administrator revealed that R1's family member takes R1 to medical appointments. Interview further revealed that R2's family members also takes R2 to medical appointments. Administrator stated if family members were unable to, Administrator is able to arrange transportation upon request. Interview with R1 revealed R1's daughter helps with medical arrangement. Interview with R2 revealed that R2's son and daughter helps arrange transportation. Additionally, R2 indicated it is not the facility's responsibility to take R2 to places.

Based on information obtained through interviews, the Department finds the allegation found the complaint to be unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

Exit interview. A copy of report and appeal rights was left at the door for Administrator to retrieve and sign. LPA requested signature copy to be faxed to LPA by close of business 9/20/2023.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie Yang	TELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023

LIC9099 (FAS) - (06/04)

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