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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 02:21:00 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
03/23/2023 and conducted by Evaluator Kerry Hiratsuka
COMPLAINT CONTROL NUMBER: 59-AS-20230323083532
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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Door knobs covered to prevent residents from going out.
INVESTIGATION FINDINGS:
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LPAs Hiratsuka and Avila, conducted this complaint visit. LPAs wore a surgical mask and observed all staff wearing masks.

LPAs toured the facility and observed one doorknob that was covered. The cover for the doorknob is one that covers it and to open the doorknob there were a couple of places for the fingers to press that created pressure between the cover and the doorknob and the doorknob could open. The doorknob that was covered is a desigated exit. Because it is a designated exit an immediate $500.00 civil penalty was issued. It was removed during visit.

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 3
Control Number 59-AS-20230323083532
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 A
03/29/2023
Section Cited
CCR
87203
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Fire Safety. All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.
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By 03/29/2023, the licensee shall submit a written statement how they are going to ensure no doorknobs for designated exits.

***$500.00 Immediate Civil Penalties issued today.
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This requirement is not met as evidenced by: Based on LPAs' observation of the doorknob being covered with a cover to prevent people from getting out and it is a designated exit. This poses an immediate risk to residents.
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*** Doorknob covered was removed during visit***
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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)
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