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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 037001001
Report Date: 01/10/2022
Date Signed: 01/10/2022 11:42:10 AM

Document Has Been Signed on 01/10/2022 11:42 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: 21DATE:
01/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:09 AM
MET WITH:Machelle Allison TIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived at this facility unannounced to conduct an annual inspection visit. LPA Valerio was screened for COVID-19 symptoms with temperature prior to being allowed inside the facility. Administrator confirmed staff and residents have not displayed any signs or symptoms of COVID-19 in the last 10 days.
 
The physical plant was toured inside and outside to ensure the safety of the residents and compliance with Title 22 regulations. There were no observed health or safety concerns. LPA conducted the infection control domain tool. LPA Valerio discussed the recent PINs and mandates with Administrator and staff. The facility has a plan to have all eligible staff boosted by the February 1st, 2022 deadline. The facility has one central entry point and has implemented screening and sign in procedures at the front of the home. LPA observed the facility to have COVID-19 informational, hand washing signs, and sign in sheet posted at the front door and throughout the facility. The facility has a designated infection control lead. The facility is able to designated and dedicated a COVID-19 bedroom and bathroom if needed.
 
LPA observed the temperature inside the facility was measured at 72*F, which is within the required range of 68 degrees F and 85 degrees F. The hot water was measured at 114.1*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 nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. LPA observed the centrally stored medications area and cleaning supplies to be locked and inaccessible to clients. Resident rooms was sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Fire extinguishers was up to date with last check on 11/26/2021.
 
Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed during this visit. An exit interview was held, and a copy of the report was left at the facility.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 01/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/10/2022
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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