Inspection Reports for Golden Pond Retirement Community

An unannounced case management visit was conducted to address deficiencies observed during complaint investigation #27-AS-20250131102041.

The investigation found that staff observed changes in a resident without proper documentation, failure to conduct required 2-hour checks, untrained Executive Director administering medications, and insufficient staffing to meet resident needs.

The visit was triggered by complaint investigation #27-AS-20250131102041. The complaint was substantiated with findings including failure to conduct required checks and untrained medication administration.

An unannounced complaint investigation was conducted regarding an allegation that the licensee was not ensuring the resident's room was kept at a comfortable temperature.

The facility responded to the complaint by attempting to repair the air conditioning, offering to relocate the resident, and providing a portable AC unit. The resident declined relocation due to adaptive furniture needs. The portable AC unit was not properly installed, resulting in inconsistent room temperature. The repair was completed on the day of the inspection. The allegation was found to be unsubstantiated due to insufficient evidence of violation.

The complaint alleged that the resident's room was not kept at a comfortable temperature. The investigation found that although there were issues with the air conditioning, the facility took appropriate steps to address the problem, and the resident declined relocation. The allegation was unsubstantiated.

An unannounced complaint investigation was conducted in response to an allegation that facility staff acted unprofessionally in front of residents.

The investigation found that a caregiver experienced a medical emergency and staff attempted to contact the Director of Care (DC), who responded inappropriately using expletives. The DC was counseled and completed a corrective communication process. No residents witnessed the event, and the allegation was found unsubstantiated due to lack of preponderance of evidence.

The allegation was that facility staff acted unprofessionally in front of residents. The event involved the DC responding inappropriately to staff calls during a medical emergency. The allegation was found unsubstantiated.

The inspection was an unannounced complaint investigation visit triggered by allegations that staff were not properly trained and that staff mishandled residents' medications.

The investigation substantiated that staff were not properly trained, with deficiencies in required medication technician training and lack of First Aid/CPR certifications. Additionally, multiple medication errors were found, including staff giving wrong medications to residents, posing immediate risk to resident health and safety.

The complaint investigation was substantiated. Allegations included improper staff training and medication mishandling. The investigation found multiple training deficiencies and medication errors, confirming the allegations.

The visit was an unannounced case management follow-up conducted after the delivery of findings from a previous complaint investigation.

The Licensing Program Analyst observed incomplete mandated training documentation in all 4 files reviewed, specifically the lack of first aid training from qualified persons such as the American Red Cross. No other deficiencies were cited during this visit.

This visit followed a previous complaint investigation (#27-AS-20250122143006) during which additional Title 22 violations were observed.

The inspection was an unannounced complaint investigation visit conducted to investigate allegations that facility staff were not conducting proper assessments and that the facility did not have sufficient staff to meet residents' needs.

The allegation that facility staff were not conducting proper assessments was substantiated, with findings showing incomplete, contradictory, or untimely resident evaluations and care plans. The allegation regarding insufficient staffing was unsubstantiated, with staff schedules reviewed and interviews indicating staffing was adequate despite some call outs.

The complaint investigation was triggered by allegations received on 08/15/2024 regarding improper resident assessments and insufficient staffing. The improper assessments allegation was substantiated, while the insufficient staffing allegation was unsubstantiated due to lack of evidence.

Licensing Program Analyst Vincent Moleski arrived unannounced to open a complaint investigation but discovered an unrelated deficiency during the visit, which was addressed in this case management report.

The facility failed to submit a resident's death report to the Community Care Licensing Division as required by regulation, posing a potential health, safety, and/or personal rights risk.

The visit was initiated as a complaint investigation but the deficiency found was unrelated to the complaint. The deficiency involved failure to submit a death report to the licensing agency.

Unannounced Case Management visit was made to continue the annual inspection of the facility.

The inspection found that all required employees had appropriate background clearances and medication administration procedures were in compliance. However, a deficiency was cited for lack of response to a call alert in a memory care resident's room, posing a potential threat to resident health and safety.

Unannounced annual inspection visit conducted by Licensing Program Analyst Kimberly Viarella to assess compliance with regulations at Golden Pond Retirement Community.

No deficiencies were cited during the inspection. The facility was found to be in compliance with food storage, fire safety, and resident room requirements. A lack of response to an emergency alert in memory care was noted and communicated to staff, and technical assistance was provided regarding non-toxic soap availability.

An unannounced case management deficiencies inspection was conducted to deliver a civil penalty following a substantiated complaint investigation regarding a questionable death of a resident.

The department found that the facility violated California Code of Regulations Title 22 by allowing a resident with dementia to possess cigarettes and lighters and to smoke unsupervised, which contributed to the resident's death. A civil penalty of $15,000 was issued for this violation.

The complaint investigation was regarding a questionable death. The allegation was substantiated, and the violation involved unsafe storage and supervision related to smoking by a resident with dementia, which led to the resident's death.

An unannounced case management deficiencies inspection was conducted to deliver a civil penalty related to a complaint about failure to respond timely to a resident's call for help, resulting in injury.

The facility staff failed to respond to a resident's call for help in a timely manner, causing the resident to fall and sustain a hip fracture. The allegation of neglect/lack of supervision was substantiated, and a civil penalty was issued for serious bodily injury.

The complaint was substantiated as staff failed to provide timely aid, resulting in the resident laying on the ground for approximately 35 minutes and sustaining a hip fracture.

The visit was an unannounced case management inspection to confirm immediate exclusion orders for a staff member (S1).

No deficiencies were cited during this visit. The facility complied with the immediate exclusion order for the staff member, who is no longer employed and removed from client contact.

The visit was an unannounced complaint investigation conducted in response to allegations received on 2024-05-08 regarding medication dispensing, call light response times, incontinence care, and commode accommodation at the facility.

The investigation found no substantiated evidence supporting the allegations. Interviews with staff and residents, record reviews, and observations indicated that medications were dispensed as prescribed, call lights were responded to within reasonable time frames, incontinence care needs were met, and commode accommodations were provided as needed.

The complaint investigation was unsubstantiated, meaning there was not a preponderance of evidence to prove or disprove the allegations that facility staff failed to dispense medications as prescribed, respond to call lights within 30 minutes, meet incontinence care needs, or provide commode accommodations.

The visit was an unannounced complaint investigation conducted in response to an allegation that staff did not keep the facility free of insects.

The Licensing Program Analyst conducted a facility tour and observation, finding the facility clean and sanitary with no insects observed. Records from a pest control company showed monthly services were provided. The allegation was determined to be unsubstantiated and no deficiencies were cited.

The complaint was unsubstantiated based on observations and pest control records; no evidence supported the allegation that staff failed to keep the facility free of insects.

An unannounced case management visit was conducted to discuss the transition of the Designated Facility Administrator who was leaving the facility on 05/31/2024.

No deficiencies were observed or cited during the visit. The facility is managing the administrator transition with an interim administrator in place.

The Licensing Program Analyst conducted an unannounced annual inspection to evaluate compliance with regulatory requirements at the Golden Pond Retirement Community Facility.

The inspection found that the facility generally met environmental and safety standards, including adequate furnishings, proper temperature controls, and sufficient food supplies. However, a deficiency was cited for failure to have an updated annual medical assessment (LIC 602) for a resident with dementia.

The inspection was conducted to investigate complaints received on 09/26/2023 regarding questionable death and medication administration at Golden Pond Retirement Community.

The investigation found the allegation of questionable death to be unsubstantiated, with no conclusive evidence that the resident's death was caused by facility actions. The medication complaint was determined to be unfounded, with no deficiencies cited.

The complaint involved allegations of questionable death and failure to obtain and dispense prescribed medications. The questionable death allegation was unsubstantiated, and the medication allegation was unfounded.

The inspection was conducted as a Case Management Deficiencies inspection to address documentation issues related to medication administration, specifically missing documentation on a resident's medication administration record (MAR) dated July 25, 2023.

The inspection found missing documentation on the resident's medication administration records for several AM medications on July 25, 2023, which posed a potential health, safety, and personal rights risk to the resident. The facility was unable to provide an explanation for the missing documentation at the time of inspection.

The visit was complaint-related, focusing on an open complaint regarding missing medication administration documentation. The report does not explicitly state substantiation status.

An unannounced complaint investigation was conducted in response to allegations received on 2023-06-12 regarding medication administration, neglect/lack of supervision, spread of scabies, and safeguarding of residents' belongings at Golden Pond Retirement Community.

The investigation found no substantiation for the allegations after interviews with staff and review of records. No deficiencies were cited, and the allegations related to medication, neglect, personal rights, and infection control were determined to be unsubstantiated due to lack of evidence.

The complaint included allegations that staff did not give resident medication, failed to address the spread of scabies, allowed residents to enter other residents' rooms due to lack of supervision, and did not safeguard residents' belongings. The investigation included interviews with six staff members and the reporting party, as well as records review. The findings were unsubstantiated.

An unannounced Case Management Deficiencies inspection was conducted to address deficiencies observed during a prior complaint inspection.

The facility failed to maintain an adequate theft and loss program as required by Health and Safety Code Section 1569.153. Staff interviews confirmed missing resident items within the last two years, but no documentation of these incidents was found since 2014 in the facility's theft/loss prevention binder.

The inspection was conducted following deficiencies observed during a complaint inspection. Staff interviews confirmed missing resident items but no allegations of theft by facility staff were made.

The visit was a Case Management - Legal/Non-compliance unannounced inspection to discuss recent compliance issues at the facility and the steps the facility is taking to address the department's concerns.

The department addressed concerns including the death of a resident, compliance with dementia care regulations, staff responses to signal systems resulting in resident injury, resident record keeping, medication administration, and elopement risk. The facility has updated policies, conducted staff training, and engaged outside consultants to address these issues. No deficiencies were cited during this visit.

An unannounced Case Management Deficiencies inspection was conducted to address deficiencies related to a reported incident dated 12/26/22 involving a resident with dementia.

The facility failed to meet Title 22 regulations regarding dementia care by allowing a resident with dementia access to cigarettes and matches/lighter, resulting in the resident's death from injuries sustained while smoking. Additionally, the facility did not provide adequate supervision to ensure the resident's health, safety, and well-being.

The inspection was complaint-related, triggered by a reported incident on 12/26/22 involving a resident with dementia who was allowed access to cigarettes and matches/lighter, leading to injuries and death. The department determined the facility did not meet regulatory requirements for dementia care and supervision.

An unannounced Plan of Correction (POC) inspection was conducted to ensure all components of the plan of correction had been completed.

The Licensing Program Analyst observed the written plan of correction and documentation of in-service training for all staff members. The plan of correction was completed and cleared, and a clearance letter was generated and provided to the facility.

An unannounced complaint investigation was conducted in response to an allegation that facility staff did not keep current and complete resident records.

The investigation substantiated the allegation that the facility failed to provide updated Physician Orders for Life Sustaining Treatment (POLST) information to all staff, resulting in incomplete and outdated resident records. A deficiency was cited for failure to maintain complete and current resident records as required by California Code of Regulations, TITLE 22.

The complaint was substantiated based on evidence that the facility obtained an updated POLST on 08/05/2023 but failed to correctly provide this information to all staff members and departments for awareness and appropriate treatment.

An unannounced complaint investigation was conducted in response to an allegation of questionable death received on 2022-12-29.

The investigation substantiated the allegation that a deceased resident with dementia had access to cigarettes, which should have been stored inaccessible according to Title 22 regulations. This violation contributed to the resident's injuries and subsequent death.

The complaint investigation was substantiated based on evidence that the deceased resident had dementia and had access to cigarettes, violating regulations and resulting in injury and death.

An unannounced complaint investigation was conducted due to allegations including questionable death, administrator qualifications, fire clearance violations, and personal rights violations related to a resident smoking in a non-designated area.

The investigation substantiated that the facility violated fire clearance regulations by allowing a resident to smoke on their balcony, which was not a designated smoking area, resulting in a fire and posing health, safety, and personal rights risks to residents. The administrator failed to enforce fire clearance rules despite knowing the violation.

The complaint investigation was substantiated. Allegations included questionable death, administrator qualifications, fire clearance violations, and personal rights violations. The department determined the facility violated fire clearance by allowing smoking in a non-designated area, resulting in a fire and risk to residents. The administrator failed to enforce fire clearance rules.

An unannounced complaint investigation was conducted in response to an allegation of cockroach infestation at Golden Pond Retirement Community.

The investigation found no evidence of insect infestation after interviews with staff and residents, and inspection of the facility. The complaint was determined to be unsubstantiated with no deficiencies cited.

The complaint alleged a violation of Personal Rights due to cockroach infestation. The allegation was unsubstantiated based on staff denial, resident interviews, and pest control records. No preponderance of evidence supported the claim.

An unannounced complaint investigation was conducted following allegations of neglect and lack of supervision after a resident sustained a fracture due to inadequate staff assistance and delayed medical attention.

The investigation substantiated that staff failed to respond timely to a resident's call pendant, resulting in the resident falling, sustaining a hip fracture, and lying on the ground for approximately 35 minutes before aid was provided. Staff admitted to communication failures and neglect in responding to the call pendant.

The complaint investigation was substantiated. The resident pressed the call pendant at 8:58pm and staff did not respond until 10:22pm. The resident fell while attempting to go to the restroom unassisted, sustained a hip fracture, and was on the ground for approximately 35 minutes before staff found him and called 911. Staff admitted to failing to respond timely and poor communication.

The inspection was conducted as a required 1 year annual inspection to evaluate the health and safety compliance of the Golden Pond Retirement Community facility.

The facility was found to be clean, odor-free, and in good repair with compliant water temperature, food supplies, fire safety equipment, and medication storage. However, a deficiency was cited for three staff files lacking current first aid certification.

The visit was conducted as a case management incident investigation following a fire that occurred on 2022-12-26 caused by a resident smoking in their room, which resulted in the resident's death.

The fire alarm system functioned properly, staff responded promptly to extinguish the fire and assist the resident, but a deficiency was cited related to failure to maintain an updated annual medical assessment for a resident with dementia, posing an immediate safety risk.

The investigation was triggered by an incident involving a fire caused by a resident smoking, resulting in the resident's death. The deficiency cited relates to care of persons with dementia and lack of updated medical assessment.

Unannounced complaint investigation visit conducted to investigate allegations of staff showing inappropriate content and making inappropriate sexual advances to a resident in care.

The allegations were found to be unsubstantiated as there was no evidence or victim identified. Interviews with staff and attempts to contact the reporting party did not corroborate the allegations. No deficiencies were noted or cited.

The complaint involved allegations of staff showing inappropriate content and making inappropriate sexual advances to a resident. The complaint was unsubstantiated due to lack of evidence and inability to identify a victim. The reporting party did not respond to interview requests.

An unannounced complaint investigation was conducted in response to an allegation that the facility directed staff to come to work with an infectious condition.

Based on interviews and statements obtained during the investigation, the allegations could not be substantiated. No staff members reported prior knowledge of a staff member working while infectious, and the staff member who tested positive was sent home after symptoms surfaced. No deficiencies were noted or cited.

The complaint was unsubstantiated. The investigation included interviews with the reporting party and six staff members who could not corroborate the allegations. The staff member who tested positive did not seek treatment prior to being informed of their status and was sent home after additional symptoms were disclosed.

An unannounced Plan of Correction (POC) inspection was conducted to review correction from citation from previous inspection and ensure all POCs had been completed by the licensee.

The Licensing Program Analyst observed that all plans of correction had been completed and met the agreed stipulations. No deficiencies were cited during this inspection.

Unannounced complaint investigation visit conducted to investigate allegations related to staff failing to meet resident's needs and violating resident's personal rights.

The allegations were found to be unsubstantiated due to conflicting statements from staff and family members. The department determined that residents have the right to choose their meals, including facility-provided food, and no violations were confirmed. No deficiencies were cited.

Complaint investigation was unsubstantiated. Allegations included staff failing to meet resident's needs and violating personal rights. Conflicting statements and lack of evidence prevented substantiation. The complaint may be amended if additional information is received.

An unannounced complaint investigation was conducted following a complaint received on 2022-03-17 regarding failure of facility staff to administer resident's medication as prescribed.

The investigation substantiated the allegation that staff did not provide prescription medications according to physician instructions, including administering blood glucose testing and insulin after the resident had started eating, contrary to physician orders.

The complaint was substantiated based on interviews with family members and staff confirming medication administration errors. The Department determined the allegation of medication error was substantiated but may be amended if additional information is received.

The visit was conducted to address the current status of the facility administrator and to verify documentation related to the administrator's appointment and qualifications.

No deficiencies were cited during the visit. The Licensing Program Analyst confirmed that the individual appointed as administrator meets all education and experience requirements, and requested submission of required documents for approval.

The inspection visit was conducted to address an incident report regarding a resident elopement that occurred on 2022-03-27.

The facility failed to ensure the continued safety of a resident with dementia who eloped from the facility without staff knowledge or supervision for over 24 hours, posing an immediate health, safety, and personal rights risk.

The visit was complaint-related due to a resident elopement incident reported on 2022-03-27. The resident was missing for over 24 hours and was returned to the facility after being located by Sacramento Police Department and family. The resident's physician stated she cannot leave the facility unassisted. The facility has since implemented 30-minute checks and updated medication orders.

The inspection was conducted as a case management visit to address medication errors observed on resident R1's medication administration logs from February and March 2022.

The Licensing Program Analyst observed several dates of insulin administration that were not marked as administered by facility medication staff, which was confirmed as an error by staff. A deficiency was cited for failure to document medication administration according to facility policy, posing an immediate health, safety, and personal rights risk to residents.

The visit was complaint-related, investigating medication errors on R1's medication administration logs. The complaint was substantiated based on observations and staff statements.

The inspection was conducted as a required 1 year annual inspection to evaluate the health and safety conditions of the Golden Pond Retirement Community facility.

The facility was found to be clean, odor-free, and in good repair with all required furniture and sufficient lighting. Water temperature, food supplies, fire safety equipment, carbon monoxide detectors, first aid kit, and medication storage were all compliant. Resident and staff files reviewed were complete and well organized. No deficiencies were cited during the inspection.

The visit was an unannounced case management visit to evaluate compliance with health and safety regulations, including review of staff FIT testing for N95 masks.

The facility was found to be following California Health and Safety Regulations with no citations or deficiencies cited during the visit. The facility was compliant with visitor screening and staff FIT testing requirements.

An unannounced case management inspection was conducted to address concerns regarding a self-reported theft of a resident's valuables.

No deficiencies were observed or cited during the inspection. The department will continue to investigate the case, and the case management remains open.

The visit was complaint-related due to concerns about a self-reported theft of a resident's valuables. The case remains open pending further investigation.

An unannounced complaint investigation was conducted in response to an allegation that facility staff were interfering with a resident's medical treatment.

The investigation found the allegation to be unfounded based on interviews and evidence; the resident and staff denied any interference with medical treatment, and no deficiencies were cited.

The complaint alleged that facility staff were interfering with a resident's medical treatment. The investigation concluded the allegation was unfounded and dismissed.

The inspection was conducted as a required 1 year annual inspection to evaluate the facility's compliance with health and safety regulations.

The facility was found to be clean, odor-free, and in good repair with all inspected rooms properly furnished and lit. Water temperatures, food supplies, fire safety equipment, carbon monoxide detectors, first aid kit, and medication storage were all in compliance. No deficiencies were cited during the inspection.

An unannounced complaint investigation visit was conducted in response to allegations that a resident sustained stage 2 pressure injuries while in care, staff did not properly maintain the facility, and the licensee did not adequately staff the facility to meet residents' needs.

The investigation found all allegations to be unfounded. The resident did not have pressure injuries but a rash being treated with medication. The facility was properly maintained with no evidence of poor housekeeping. Staffing was adequate with residents checked regularly and no evidence of neglect.

The complaint was investigated and found to be unfounded, meaning the allegations were false, could not have happened, or were without reasonable basis. The complaint involved allegations of pressure injuries, poor facility maintenance, and inadequate staffing.

Unannounced complaint investigation visit conducted in response to multiple allegations regarding staff not following resident toileting needs, diabetic care, timely response to alerts, sanitation practices, laundry services, and feeding residents.

The investigation found insufficient evidence to substantiate the allegations. Staff documentation and interviews indicated compliance with care standards, but some documentation gaps prevented full verification. No deficiencies were cited.

The complaint investigation was unsubstantiated, meaning there was not a preponderance of evidence to prove the alleged violations occurred. Allegations included failure to follow toileting needs, diabetic care, timely response to alerts, sanitation, laundry services, and feeding residents.

The inspection was an unannounced complaint investigation triggered by allegations received on 2020-05-12 regarding rough handling of a resident causing bruises and improper training of kitchen staff.

The investigation found no preponderance of evidence to substantiate the allegations. The resident's bruising was not documented in shower sheets and staff reported no observed bruising. Kitchen staff who prepared food had proper food handler certificates, while servers did not require them. Both allegations were deemed unsubstantiated.

The complaint involved two allegations: 1) staff handled a resident roughly causing bruises, and 2) kitchen staff lacked proper food handler training. Both allegations were investigated and found unsubstantiated due to lack of evidence.