342700512-9-20-2023-25-AS-LMUZ-CVVV5E-20230921160745

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700512
Report Date: 09/20/2023
Date Signed: 09/20/2023 12:27:09 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
03/06/2023 and conducted by Evaluator Cassie Yang

COMPLAINT CONTROL NUMBER: 25-AS-20230306154540

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:	08:50 AM
MET WITH:	Oliver Fule		TIME COMPLETED:	10:15 AM

ALLEGATION(S):

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Staff conduct poses a risk to residents in care.

INVESTIGATION FINDINGS:

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On 9/20/2023, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to deliver the finding for the allegation listed 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.

Result is as follow, please continue report on LIC 9099-C...

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 25-AS-20230306154540

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

Allegation: Staff conduct poses a risk to residents in care.

The Department conducted extensive interviews, it revealed R1 and R2 have no concerns with staff at the facility. Interview with R1 and R2 further revealed R1 and R2 have not seen and/or encountered staff being aggressive or a threat to residents in care. Interview conducted with R1’s family member revealed there are no concerns with staff’s behavior at the facility. Based on interview conducted with Administrator, it revealed there has been no concerns with staff aggression at the facility. Administrator stated he has not received any reports from residents in care of negative behaviors from staff.

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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