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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 037001001
Report Date: 12/28/2022
Date Signed: 12/28/2022 03:25:44 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
09/29/2022 and conducted by Evaluator Christina Valerio
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220929140325
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: 25DATE:
12/28/2022
UNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Facility StaffTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility is violating resident's personal rights
Facility did not complete an updated needs and service plan
Facility is sharing information with unauthorized representative
Facility is not meeting food service requirements
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to deliver complaint investigation findings. LPA met with facility lead staff, and explained the purpose of the visit.

The department has determined the following as it relates to the allegations: Facility is violating resident's personal rights, Facility did not complete an updated needs and service plan, Facility is sharing information with unauthorized representative, Facility is not meeting food service requirements

According to interviews with staff, staff have never observed or admitted to violating any resident's personal rights. According to staff, they continue to provide care and ensure their needs are met as best as they can. One staff stated, "If someone were to ask for help, I would help them. If I was getting paid or not, I am here for the residents." According to resident interviews, the staff are nice, treat the resident's good, and the facility is a good place. According to facility observations, LPA did not observe any personal rights violation on 10/04/22, 10/20/22, 11/18/22, or 12/28/22.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2022
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 27-AS-20220929140325
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
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 HOME
FACILITY NUMBER: 037001001
VISIT DATE: 12/28/2022
NARRATIVE
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LPA reviewed facility records for resident's on hospice. Resident 1 had an assessment completed on 10/11/2017. According to records, an updated assessment was done in 2021. For 2022, a care plan was re-established on 03/03/22 and 04/27/22. Resident 1 also had an updated LIC 602 with a date of 03/10/2022. According to staff interviews, care plan assessments are completed in their QUICK MAR system. According to an interview with an outside agency, the facility listed a patient (resident 2) on hospice with dementia; however, the resident does not have dementia. According to a previous staff, R2 has always been observed to be coherent and should not have been diagnosed with dementia. According to records review, the facility had a care plan updated on 03/24/22 and 08/02/22. According to an interview with the assistant administrator, a nurse diagnosis R2 with dementia during a visit. The assistant administrator asked for proof regarding the diagnosis to ensure the care plan is accurate.

LPA Valerio interviewed residents, staff, and an outside agency regarding staff sharing resident information with unauthorized representatives. According to two interviews, it was heard that staff are taking videos of residents on their cell phone and then laughing about it. One staff stated, "I know we have used snap chat filters to have it for fun during activities. We always ask for consent. We post them in our activities room and/or for Facebook. We have all residents sign a consent form." LPA reviewed resident records and confirmed that each resident has a signed consent for photographs/videos to be taken for the purpose of activities, newsletters, and family. According to staff, a sign was created because staff were discussing who left to the hospital with another resident. The sign posted stated, "We are not to share any personal information on the resident, yourself or any other person in the community." According to an interview with R2, R2 stated there was an issue with R2's family member for about a week. R2 stated R2 is involved in treatment meetings and has appointed a new power of attorney.

LPA interviewed staff regarding the facility's food service. Staff stated there is an ample amount of food, they try to make everything in house, they give options to resident's, they will offer seconds to resident, they have a dietitian make the menu, and they adjust the menu based on resident wants, supply, and diet. Other staff stated that depending on the cook staff, there might be a change in presentation for food. One cook staff only cooks frozen foods and another staff cooks home-made meals.

Continues on LIC 9099- C...
page 2 of 3
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20220929140325
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
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 HOME
FACILITY NUMBER: 037001001
VISIT DATE: 12/28/2022
NARRATIVE
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According to another staff, the staff will order food and lead management will adjust the order based on budget. There are times where the facility does not get everything that was initially ordered. According to a family member, the food smelled so good, they wanted to stay for dinner. Based on observations of meal times and the facility menu, the facility offers balanced and appetizing food items. According to an interview with a  resident, resident stated, "they have a variety of food, such as ground beef, pulled pork, and chicken."

Based on all the information collected by the Department there is not a preponderance of evidence to prove the allegation occurred, therefore this allegation is UNSUBSTANTIATED.  Due to the above noted information, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, and therefore the allegations are unsubstantiated.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited.  Exit interview was held and a copy of report was given to facility lead staff.

Page 3 of 3.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3