037001001-9-10-2024-27-AS-KHOS-D93TZQ-20240913151042

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 037001001
Report Date: 09/10/2024
Date Signed: 09/10/2024 05:05:59 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/12/2024 and conducted by Evaluator Arvin Villanueva

COMPLAINT CONTROL NUMBER: 27-AS-20240312154531

FACILITY NAME:	GOLD QUARTZ INN RETIREMENT HOME		FACILITY NUMBER:	037001001
ADMINISTRATOR:	LOREEN HICKMAN		FACILITY TYPE:	740
ADDRESS:	15 BRYSON DRIVE		TELEPHONE:	(209) 267-9155
CITY:	SUTTER CREEK	STATE: CA	ZIP CODE:	95685
CAPACITY:	47	CENSUS: 23	DATE:	09/10/2024
		UNANNOUNCED	TIME BEGAN:	04:24 PM
MET WITH:	Loreen Hickman		TIME COMPLETED:	05:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility did not provide responsbile party with former resident's records.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 9/10/24 at 4:24pm, Licensing Program Analyst (LPA) Arvin Villanueva arrived at this facility unannounced to conduct a follow up complaint visit and deliver finding regarding the allegation noted above. LPA met with Loreen Hickman, Administrator and stated the purpose of this visit.

The investigation involved conducting interviews and reviewing records from a prior complaint (control # 27-AS-20230816155055), alongside other pertinent documents, to address the allegation that Gold Quartz Inn Retirement Home (GQI) did not provide the Responsible Party (RP) with the records of the former resident (R1).

Initially, the RP requested records on 6/13/23, prior to R1's death. RP requested comprehensive documentation since R1's admission on 11/1/22. On 6/16/23, the facility provided some documents to the RP; however, several pages, including those from the Hospice binder, were missing or incomplete.
In response to subsequent requests from the RP on 6/25/23, and 6/28/23, which highlighted the missing pages and documents, the facility communicated further updates.

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024

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 2

Control Number 27-AS-20240312154531

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GOLD QUARTZ INN RETIREMENT HOME	FACILITY NUMBER: 037001001
	VISIT DATE: 09/10/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

On 628/23, the facility informed the RP that the missing pages from the hospice documents were not available due to being provided in incomplete form by the hospice provider.

Following R1's death, the RP, also the Power of Attorney (POA), formally requested a complete set of records on 8/11/23. GQI responded by stating that while they would provide some documents, they could not release all requested records due to regulatory and contractual limitations.

A regulatory and legal review revealed that the Department of Social Services indicated that a POA’s authority terminates upon the resident's death. Consequently, the facility was not obligated to release resident records after their death. GQI’s position was that no specific law required them to release all requested records after the resident’s death, though they did agree to provide payment records and relevant care documents.

The facility had provided the majority of the requested documents, excluding those from the hospice, which were property of the hospice provider and not directly controlled by GQI. Administrator Loreen Hickman and Licensee Ronald Regan confirmed that the facility had furnished all available documents and addressed any missing pages from their own records. The remaining documents were under the hospice provider's control.

An appeal of the facility’s actions was reviewed, and the Department concluded that GQI’s response adhered to regulatory requirements. The facility had complied with providing all available records and clarified that some documents were beyond their control.

In conclusion, the investigation found no evidence that the facility did not provide the requested records beyond their control or contrary to regulatory obligations. Therefore, the allegation is deemed UNFOUNDED. Note that a finding that is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

Based on today’s visit, no deficiencies are being cited. After discussing the findings, Administrator needed to leave the facility and assigned staff on duty (S1) to sign this report on behalf of the Administrator, An exit interview was conducted with S1 and a copy of this report was provided.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2