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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 037001001
Report Date: 04/16/2024
Date Signed: 04/16/2024 10:41:51 AM


Document Has Been Signed on 04/16/2024 10:41 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:GOLD QUARTZ INN RETIREMENT HOMEFACILITY NUMBER:
037001001
ADMINISTRATOR:LOREEN HICKMANFACILITY TYPE:
740
ADDRESS:15 BRYSON DRIVETELEPHONE:
(209) 267-9155
CITY:SUTTER CREEKSTATE: CAZIP CODE:
95685
CAPACITY:47CENSUS: 26DATE:
04/16/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:25 AM
MET WITH:Loreen HickmanTIME COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to the facility to conduct a case management - deficiencies visit. LPA met with Administrator Loreen Hickman, and explained the purpose of the visit.

On 09/26/2023, The Regional Office substantiated allegations for complaint 27-AS-20230920142634. The Licensee appealed the decision. The appeal was granted, and the citation with the related $500 civil penalty was dismissed. However, a violation still exists for 22 CCR § 87468.2(a)(4) for staff failure to ensure R1’s wheelchair lock in the transport van was secured resulting in R1 and the wheelchair falling to the floor.

LPA toured the facility and observed no immediate health or safety concerns. LPA requested and obtained a copy of the current staff roster.

Per California Code of Regulations (CCR) - Title 22, deficiencies are being cited on the attached LIC 809-D page. Appeal Rights were provided. An exit interview was held, a copy of the report was provided.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 04/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 04/16/2024 10:41 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: GOLD QUARTZ INN RETIREMENT HOME
FACILITY NUMBER: 037001001

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/23/2024
Section Cited
CCR
87468.2(a)(4)

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87468.2 Additional Personal Rights of Residents...(a)In additionto...Section 87468.1... residents... shall have all of the following personal rights: (4)To care, supervision, and services that meet their individual needs...This requirement was not met as evidenced by:
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Licensee to submit copies of in-service training for Transportation Procedures conducted for 2023 and 2024 for all staff by POC due date.
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Based on records review and interviews, the licensee neglected to ensure R1's needs were met by staff, which resulted in R1 falling to the floor while in a moving vehicle. This poses a potential health and personal rights risk to residents in care.
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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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 04/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2024
LIC809 (FAS) - (06/04)
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