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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 037001001
Report Date: 05/28/2026
Date Signed: 05/28/2026 02:13:48 PM

Unsubstantiated


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
02/26/2026 and conducted by Evaluator Pang Lee
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20260226152218
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: 34DATE:
05/28/2026
UNANNOUNCEDTIME BEGAN:
08:38 AM
MET WITH:Brandee ButlerTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Facility toilet is in disrepair
Facility staff did not provide resident's records to authorized representative
Facility staff do not safeguard resident's belongings
Facility staff not providing a comfortable environment for the resident
Facility did not ensure that resident reappraisals were conducted
INVESTIGATION FINDINGS:
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On 05/28/2026, Licensing Program Analyst (LPA) Pang Lee arrived unannounced at the facility to conduct a complaint visit. LPA Lee met with Assistant Administrator (AA) Brandee Butler and explained the purpose of the visit. The purpose of today’s visit was to deliver the complaint findings regarding the above allegations. Per AA Butler, Administrator Loreen Hickman was off duty today. The current census was 34. A brief interview was conducted with AA Butler.

It was alleged that the facility toilets were in disrepair. The investigation included observations and interviews with staff and residents. During LPA Lee’s facility visit on 03/03/2026, LPA Lee inspected nine residents’ toilets, including Resident 1’s (R1) toilet in room 102, and observed that all toilets were in good repair and functioning properly. During LPA Lee’s facility visit on 04/23/2026, LPA Lee inspected five additional residents’ toilets, including R1’s toilet, and again observed that all toilets were in good repair and functioning properly.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2026
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 7
Control Number 27-AS-20260226152218
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: 05/28/2026
NARRATIVE
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 Interviews were conducted with six out of six staff members, all of whom stated that the residents’ toilets were in good repair. Staff members also denied instructing residents to dispose of used toilet paper in trash bins instead of flushing it. Additionally, twelve out of twelve residents interviewed reported that the toilets were not in disrepair. Furthermore, eleven out of eleven residents stated that facility staff had not instructed them to dispose of used toilet paper in trash bins. Based on the investigation, it was further learned that toilets may occasionally clog depending on usage; however, maintenance staff are readily available to address and unclog toilets to restore proper function. Based on the observations and interviews conducted, LPA Lee was unable to corroborate the allegation.

It was alleged that facility staff did not provide resident’s records to authorized representatives. The investigation included interviews with the Administrator Hickman and a review of records. On 02/01/2026, it was learned that the resident’s authorized representative requested Resident 1 (R1)’s records, specifically pendant call logs. It was further noted that the facility’s call system retains only 16 pages of call history. On 02/05/2026, the authorized representative requested additional documents, including all communication logs that are posted on R1’s refrigerator. On 02/11/2026, Administrator Hickman explained to the authorized representative the facility’s protocol for releasing records and provided the authorized representative with an Authorization for Use and Disclosure of Protected Health Information form to state that authorized representative can obtain R1’s records. It was also learned that the Power of Attorney documentation that the authorized representative provided to the facility was limited to financial matters and did not include access to medical records. The facility contacted and discussed this matter with the authorized representative. On 02/13/2026, the authorized representative submitted the signed Authorization for Use and Disclosure of Protected Health Information form, and it was learned that the authorized representatives were 4th in line. On 02/16/2026, authorized representative sends signed authorization for use and disclosure of protected health information form. On 02/26/2026, the authorized representative requested additional and all records and documents related to R1’s stay at the facility from date of admission 11/05/2024 to 03/18/2026. On 03/03/2026, all requested documents were collected and taken to the corporate office for copying, and the authorized representative was notified that the copies were ready to pick up. The authorized representative confirmed via email that they would retrieve the documents. Based on the record review, there was ongoing communication between the facility and the authorized representative regarding the requested documents and the requested records were provided to the authorized representative. Therefore, based on the records review and interviews conducted, LPA Lee was unable to corroborate the allegation.
CONTINUED LIC 9099-C
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 27-AS-20260226152218
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: 05/28/2026
NARRATIVE
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It was alleged that facility staff do not safeguard residents’ belongings. The investigation included observations and interviews with facility staff and residents in care. During the investigation, it was learned that Resident 1’s (R1’s) pillowcase and mask were not returned after being washed that week. Based on observations made during facility visits conducted on 03/03/2026 and 04/23/2026, LPA Lee observed in the laundry room that residents’ clothing was labeled with their name and initials. Resident bedding and sheets were folded, bagged, and prepared for delivery to residents after laundering. Interviews with six out of six facility staff revealed that residents’ belongings are labeled with the resident’s name and initials, and any unlabeled items were placed in the lost and found area. The laundry area was organized, and a system was in place for processing residents’ laundry. LPA Lee also observed a designated area in room 113 for residents’ lost items, where residents and family members could access and look for unidentified belongings that did not have names labeled on them. Interviews with 12 out of 12 residents indicated that they had no concerns regarding the facility’s laundry services or staff safeguarding residents’ belongings. R1 stated that the pillowcase and mask had been returned and has no concerns anymore. Based on observations and interviews conducted, LPA Lee was unable to corroborate the allegation.

It was alleged that facility staff did not provide a comfortable environment for the residents. The investigation included observations and interviews with facility staff and residents. Based on observations made during facility visits conducted on 03/03/2026 and 04/23/2026, LPA Lee did not observe facility staff making residents feel uncomfortable. During both visits, facility staff were observed assisting residents with their activities of daily living (ADLs), and no mistreatment of residents by staff was observed. Interviews conducted with six out of six facility staff revealed that they had not witnessed any staff mistreating residents or making residents feel uncomfortable. Interviews with 10 out of 12 residents indicated that they had no concerns regarding staff not providing a comfortable environment. Additionally, the 10 residents stated that they felt safe living in the facility and had no concerns regarding facility staff. Based on observations and interviews conducted, LPA Lee was unable to corroborate the allegation.

It was alleged that the facility did not ensure resident reappraisals were conducted. Based on the investigation, including records review and interviews, it was learned that Resident 1 (R1) moved into the facility on 11/05/2024. A pre-admission questionnaire and LIC 603 Pre-Placement Appraisal were completed on 09/09/2024.

CONTINUED LIC 9099-C

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 27-AS-20260226152218
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: 05/28/2026
NARRATIVE
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An Augmented Standard Assessment/Care Plan for R1 was later completed on 01/24/2025 and signed by both Administrator Hickman and R1’s Responsible Party (RP). Additionally, a LIC 625 Appraisal/Needs and Services Plan was completed on 01/21/2026; however, the document was not signed either by either the Administrator Hickman or RP. According to an interview with Administrator Hickman, R1’s RP took the LIC 625 document dated on 01/21/2026 for review and signature but did not return the completed form. Administrator Hickman further stated that the RP provided the facility with a 30-day notice on 02/18/2026, and R1 then moved out of the facility on 03/18/2026; therefore, the form was never returned signed. Based on an interview with the RP, it was confirmed that facility staff did provide them with a document for review and signature. However, the RP stated that R1 was hospitalized at the time, and they did not have the opportunity to review and sign the document and that they could not recall which specific document was provided and were unable to locate the paperwork. Based on the records reviewed and interviews conducted, it could not be confirmed whether the document provided to the RP was the resident’s reappraisal, as the RP was unable to recall which form had been provided; therefore, LPA Lee was unable to corroborate the allegation.

The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred.



An exit interview was conducted with AA Butler, and a copy of the LIC 9099 report was provided to the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 7
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
02/26/2026 and conducted by Evaluator Pang Lee
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20260226152218

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: 34DATE:
05/28/2026
UNANNOUNCEDTIME BEGAN:
08:38 AM
MET WITH:Brandee ButlerTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Facility did not ensure residents received their medications timely
INVESTIGATION FINDINGS:
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On 05/28/2026, Licensing Program Analyst (LPA) Pang Lee arrived unannounced at the facility to conduct a complaint visit. LPA Lee met with Assistant Administrator (AA) Brandee Butler and explained the purpose of the visit. The purpose of today’s visit was to deliver the complaint findings regarding the above allegations. Per AA Butler, Administrator Loreen Hickman was off duty today. The current census was 34. A brief interview was conducted with AA Butler.

It was alleged that the facility did not ensure residents received their medications timely. The investigation included a review of Resident 1’s (R1) medication administration records. Based on a review of the facility’s QuickMAR records for R1 from January 2025 through January 2026, ten multiple medication entries on various dates and times were left blank and did not contain staff initials documenting administration of the medications. Furthermore, a review of the QuickMAR back-page notes revealed no documented explanation for why they were left blank, including no indication that the medications were refused, held, unavailable, discontinued, or otherwise not administered.
CONTINUED LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 27-AS-20260226152218
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: 05/28/2026
NARRATIVE
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According to Administrator Hickman, via an email on 05/27/2026, when a resident’s medication entry contains staff initials, it indicates that the medication was administered. If the staff initials are circled, it indicates that the resident refused the medication. Administrator Hickman further stated that if there are no staff initials and the entry is left blank, it means the medication was not administered to the residents.

During today’s visit on 05/28/2026, LPA Lee reviewed the 10 dates and times on the QuickMAR that were left blank with AA Butler, and AA Butler acknowledged that there were no staff initials or documented explanations indicating why the medications were not administered to R1 on those dates and times and was not able to provide LPA Lee any reasons. Therefore, based on the blank entries observed in the QuickMAR records, the facility was unable to demonstrate that the medications were administered as prescribed, LPA Lee was able to corroborate the allegation that the facility did not ensure residents received their medications timely.

As a result of this investigation, the Department finds the allegation to be SUBSTANTIATED. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

An exit interview was conducted with AA Butler, and a copy of the LIC 9099 reports, LIC 9099-D page, and Appeals rights were provided to the facility.

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 27-AS-20260226152218
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/28/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/11/2026
Section Cited
CCR
87465(a)(4)
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87465 (a)(4) Incidental Medical and Dental Care
(a)A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
(4)The licensee shall assist residents with self-administered medications as needed.

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AA Butler/facility agrees to conduct staff training regarding medication administration and medication record-keeping by the POC due date 06/11/2026 end of day 5:00 PM. Administrator agrees to email LPA Lee a copy of the training
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This requirement is not met as evidenced by:
Based on interviews and record reviews, the licensee did not comply with the regulation cited. Facility did not ensure medications were administered to R1 as prescribed. This poses immediate health, safety, and personal rights risks to persons in care.

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materials used for the training and staff sign-in sheet for attending the training.

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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.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2026
LIC9099 (FAS) - (06/04)
Page: 7 of 7