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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347001254
Report Date: 06/07/2021
Date Signed: 06/07/2021 09:07:32 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
02/14/2020 and conducted by Evaluator Donna Gurriere
COMPLAINT CONTROL NUMBER: 27-AS-20200214134721
FACILITY NAME:GOLDIN CARE 1FACILITY NUMBER:
347001254
ADMINISTRATOR:LARA WINKLERFACILITY TYPE:
740
ADDRESS:108 REMINGTON DRIVETELEPHONE:
(916) 983-1721
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY:6CENSUS: 2DATE:
06/07/2021
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:DANIELLE HAZZIEZTIME COMPLETED:
09:45 AM
ALLEGATION(S):
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Facility staff did not get a pre-admission appraisal for Resident 1.
INVESTIGATION FINDINGS:
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Donna Gurriere, Licensing Program Analyst was in contact with Danielle Hazziez, Administrator. The allegations pertain to a resident referred to as Resident 1. The following allegation was investigated:

Facility staff did not get a pre-admission appraisal for Resident 1.

An investigation was conducted and during that time, several documents were obtained. Documents included Physician’s Reports, Pre-Admission Appraisals, Admission Agreements, a list of staff persons, a list of current residents, medical records, medication list, hospital records and a fall prevention policy. In addition, the previous Licensee, previous Administrator, previous resident (Resident 1), previous Occupational Therapist, previous Physical Therapist, current Administrator, two current care providers and a current resident were interviewed. It is noted that staff persons that were working when Resident 1 was residing at the facility are no longer employed and could not be interviewed.


Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Rayna L BrysonTELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (530) 895-5033
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2021
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 3
Control Number 27-AS-20200214134721
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: GOLDIN CARE 1
FACILITY NUMBER: 347001254
VISIT DATE: 06/07/2021
NARRATIVE
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**continued**

Facility staff did not get a pre-admission appraisal for Resident 1.
During the interview process, the previous licensee and administrator were interviewed, including Resident 1. An Appraisal/Needs and Services Plan was received for the resident, and dated 11/11/19, which was signed by the licensee. The resident’s move in date was 11/10/19. The appraisal and needs plan provided an outline of what type of needs were required for the resident, while staying at the facility. Although the Appraisal/Needs and Services Plan was a day late and was completed by the licensee, the records did not indicate that the resident’s representative, signed the document, as required.

Based on the evidence obtained, the preponderance of evidence standard has been met; therefore, the allegation is found to be Substantiated. California Code of Regulations (Title 22) is being cited on the attached LIC 9099D. Appeal rights are provided, and a closure interview was conducted.
SUPERVISOR'S NAME: Rayna L BrysonTELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (530) 895-5033
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 27-AS-20200214134721
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: GOLDIN CARE 1
FACILITY NUMBER: 347001254
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/14/2021
Section Cited
CCR
87457(a)
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Pre-Admission Appraisal - Prior to admission, the prospective resident and his/her responsible person, if any, shall be interviewed by the licensee or the employee responsible for facility admissions.
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The current administrator shall submit a policy outlining the requirements for a Pre-Admission Appraisal.
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Based upon LPA Gurriere’s review of records and interviews of staff and the resident, the previous licensee did not ensure that the Pre-Admission Appraisal was completed timely and signed by the resident’s authorized representative.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Rayna L BrysonTELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (530) 895-5033
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3