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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 037001001
Report Date: 11/10/2021
Date Signed: 11/10/2021 11:19:58 AM

Document Has Been Signed on 11/10/2021 11:19 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:GOLD QUARTZ INN RETIREMENT HOMEFACILITY NUMBER:
037001001
ADMINISTRATOR:MACHELLEE ALLISONFACILITY TYPE:
740
ADDRESS:15 BRYSON DRIVETELEPHONE:
(209) 267-9155
CITY:SUTTER CREEKSTATE: CAZIP CODE:
95685
CAPACITY: 47CENSUS: 20DATE:
11/10/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Machellee AllisonTIME COMPLETED:
11:25 AM
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct an annual inspection. LPA met with facility staff Loreen Hickman, stated the purpose of today’s visit, and was allowed entry after being screening for COVID-19 symptoms with temperature taken. Staff confirmed residents and staff have not had any signs or symptoms of COVID-19 in the last 10 day.

The physical plant was toured inside and outside to ensure the safety of the residents and compliance with Title 22 regulations. LPA also conducted the infection control domain tool. The facility submitted a LIC 808 mitigation plan. LPA observed the facility to have a first aid kit, hand washing signage, and COVID - 19 informational signage posted at the front door and throughout the facility. The facility is able to designate and dedicated a Covid-19 bedroom and bathroom if needed. Common touch surfaces are cleaned after each use.

LPA observed the temperature inside the facility was measured at 74*F which is within the required range of 68 degrees F (20 degrees C) and 85 degrees F (30 degrees C), or in areas of extreme heat the maximum shall be 30 degrees F (16.6 degrees C) less than the outside temperature.  The hot water was measured at 110.1 *F, which is not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C) as per Title 22 regulations. Facility has food supplies: nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. The centrally stored medications area to be locked and inaccessible to clients. LPA Valerio observed a pull alarm system, fire extinguisher(s) with last check on 11/20/2020, smoke and carbon monoxide detectors, central heating and air in the facility.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies observed or cited.  Exit interview held, copy of report given to Administrator Machellee Alllison.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 11/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/10/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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