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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 455002976
Report Date: 03/28/2023
Date Signed: 03/28/2023 02:18:16 PM

Substantiated


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
03/24/2023 and conducted by Evaluator Kerry Hiratsuka
COMPLAINT CONTROL NUMBER: 59-AS-20230324141842
FACILITY NAME:GOLDEN OAKS SENIOR LIVINGFACILITY NUMBER:
455002976
ADMINISTRATOR:WILLIAMS, KENNETHFACILITY TYPE:
740
ADDRESS:779 KERRYJEN CT.TELEPHONE:
(530) 223-1538
CITY:REDDINGSTATE: CAZIP CODE:
96002
CAPACITY:26CENSUS: 14DATE:
03/28/2023
UNANNOUNCEDTIME BEGAN:
12:13 PM
MET WITH:Melissa JohnsonTIME COMPLETED:
02:27 PM
ALLEGATION(S):
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Faciity did not admit resident properly
INVESTIGATION FINDINGS:
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LPAs Hiratsuka and Avila, conducted this unannounced complaint visit. LPAs wore a surgical mask and observed alls staff wearing masks.

LPAs reviewed the resident in question's file. The file is missing the following: admission agreement, completed pre-appraisal, personal rights, client personal belongings inventory list, medical release, and consent forms. The resident moved in the beginning of this month and the file is not complete.

Based on the above, the allegation is substantiated.

Deficiencies cited from Title 22 Regulations and or the California Health and Safety Code. Failure to correct shall result in civil penalties. appeal rights left
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2023
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 59-AS-20230324141842
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 OAKS SENIOR LIVING
FACILITY NUMBER: 455002976
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/28/2023
Section Cited
CCR
87506(a)
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Resident Records. The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff
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By 04/28/2023, the licensee shall submit in writing a plan of correction on how they shall ensure resident's files are complete upon move in.
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This requirement is not met as evidenced by: Based on LPAs review of the resident's file, it is missing a lot of documentation. This does not pose an immediate risk to residents.
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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: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2