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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 037001001
Report Date: 05/04/2023
Date Signed: 05/04/2023 03:40:53 PM

Document Has Been Signed on 05/04/2023 03:40 PM - 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:LOREEN HICKMANFACILITY TYPE:
740
ADDRESS:15 BRYSON DRIVETELEPHONE:
(209) 267-9155
CITY:SUTTER CREEKSTATE: CAZIP CODE:
95685
CAPACITY: 47CENSUS: DATE:
05/04/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Fleta HerndonTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Christina Valerio and Licensing Program Manager (LPM) Stephen Richardson arrived to the facility unannounced to follow up on an incident that occurred on 04/27/2023. LPA met with facility staff and Senior Executive Director Fleta Herndon, and explained the purpose of the visit.

The incident report stated that on 04/27/23 at 11:15 AM, Resident 1 (R1) was being transported to an appointment with Staff 1 (S1) and Staff 2 (S2). S1 was driving the facility van while S2 was sitting in the back of the van behind R1. S1 made a turn going 5 miles per hour. While turning, R1 fell while still in their wheelchair, landing on the the floor and on their right side of their body. S2 assisted by elevating R1's head while on the vehicle floor. S2 performed verbal checks and assisted R1 back into the wheel chair after the fall and secured R1 to continue transportation to R1 appointment. R1 was observed to have a skin tear. S2 performed first aid. R1 was on the way to the doctor's office. R1's responsible party and primary care provider was notified. The doctor's office re-bandaged R1's injury and R1 will be provided home health follow up care.

The facility reported the incident to LPA on 05/01/23 and sent in an incident report on 05/03/23. During a phone conversation with Administrator Loreen, Administrator stated they are conducting an internal investigation and will send copies of the staff statements to LPA. Per Administrator, the van was assessed by the maintenance worker. The van is in working condition and was used to transport residents.

LPA requested facility documentation related to the incident. Facility staff provided doctor visit documentation. LPA requested staff statements. Licensee Ron informed Fleta that he will not release the statements to LPA based on the guidance provided by their attorneys. The attorneys were to review the statements and give approval to release the statements. LPA provided Technical Assistance to Fleta to inform and remind Licensee Ron of Title 22 87755 (c), which states, "The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the requirements in Sections 87412(f), 87506(d), and 87508(b)."
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/04/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/04/2023
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Continues from LIC 809...

At 11:12 AM, LPA Valerio and LPM Richardson received an email composed of the statements from staff that were present before and after the incident. Staff statements were reviewed.

On 05/02/23, the regional office was sent a picture of R1's injuries. The picture was reviewed and details were documented. Based on review, the picture indicates an approximate 1 and 1/2 inch skin tear with evidence of ecchymosis "bruising" on the entirety of the upper forearm. According to staff interviews, staff have not seen the injury recently due to home health taking care of the skin tear. Staff stated the resident has attended follow-up appointments and will continue to receive follow up care from home health.

LPA requested personnel files and staff training records. LPA observed 3 staff files. LPA and LPM did not observe staff in-service training pertaining to how to properly secure wheelchairs into the facility van or topics related to operating the facility van. During facility records review, the licensee did not ensure 3 out 3 staff files reviewed had up-to-date training. S1 received 13 hours of training in 2022 and 0.75 hours of training in 2023. S2 had 0 hours of training received for 2022 and 2023. S3 received 14 hours of training in 2022 and 0 hours of training in 2023. This poses a potential health and safety risk to residents in care.

Per California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, deficiencies were observed and citations can be found on LIC 809 - D. Failure to correct the deficiencies may result in civil penalties. An exit interview was held with Senior Executive Director Fleta Herndon, and a copy of the report was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/04/2023 03:40 PM - It Cannot Be Edited


Created By: Christina Valerio On 05/04/2023 at 12:35 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: GOLD QUARTZ INN RETIREMENT HOME
FACILITY NUMBER: 037001001

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
05/05/2023
Section Cited
CCR
87707(a)(2)

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87707 Training Requirements...(a) Licensees.. shall...meet the following training requirements: (2) Direct care staff shall complete at least eight hours of in-service training...within 12 months of working in the facility and in each succeeding 12-month period... This requirement was not met as evidenced by:
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Licensee stated all facility staff will receive in-service training. Licensee to send LPA a copy of in-service training with staff signatures acknowledging understanding of "Procedures to Transport a Wheelchair Resident in Gold Quartz Van"
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Based on observations, records review, and interviews, the licensee did not ensure staff received updated training on how to properly secured residents with a wheelchair in the facility van. This resulted in a resident getting injured during transport, which poses an immediate health and safety risk to residents in care.
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Type B
06/01/2023
Section Cited
CCR87411(c)

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87411 Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69
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Licensee stated the administrator will go through all staff files to determine which files are out of date.
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Based on records review and interviews, the licensee did not ensure 3 out of 3 staff files reviews received required annual training. This poses a potential health and safety risk to residents in care.
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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:Stephen Richardson
LICENSING EVALUATOR NAME:Christina Valerio
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2023


LIC809 (FAS) - (06/04)
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