Inspection Reports for
Golden Pond Retirement Community
3415 Mayhew Rd, Sacramento, CA 95827, United States, CA, 95827
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
6.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
63% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
49% occupied
Based on a February 2026 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Annual Inspection
Census: 86
Capacity: 175
Deficiencies: 0
Date: Feb 27, 2026
Visit Reason
Licensing Program Analyst Christina Valerio arrived unannounced to conduct an annual required inspection to ensure compliance with Title 22 regulations.
Findings
No deficiencies were observed during the visit. The facility was found to be clean, well-maintained, with properly functioning equipment and safety measures in place. Due to time constraints, resident and staff files were not reviewed and will be reviewed at a later date.
Report Facts
Facility capacity: 175
Census: 86
Hot water temperature: 111.3
Date of last fire/emergency drill: Feb 19, 2026
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christina Valerio | Licensing Program Analyst | Conducted the annual inspection and authored the report |
| Ryan Nakao | Administrator | Facility administrator who met with the Licensing Program Analyst during the inspection |
| Stephen Richardson | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Annual Inspection
Census: 86
Capacity: 175
Deficiencies: 0
Date: Feb 27, 2026
Visit Reason
Licensing Program Analyst Christina Valerio arrived unannounced to conduct an annual required inspection to ensure compliance with Title 22 regulations.
Findings
No deficiencies were observed during the visit. The facility was found to be clean, well-maintained, and in compliance with regulations, including fire safety and resident room conditions.
Report Facts
Facility capacity: 175
Resident census: 86
Hot water temperature: 111.3
Date of last fire/emergency drill: Feb 19, 2026
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christina Valerio | Licensing Program Analyst | Conducted the annual inspection and authored the report |
| Ryan Nakao | Administrator | Facility administrator met with Licensing Program Analyst during inspection |
| Stephen Richardson | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 175
Deficiencies: 0
Date: Feb 11, 2026
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations that unqualified staff dispensed medication, medications were not dispensed as prescribed, and medications were not properly managed for residents.
Complaint Details
The complaint alleged that on July 4, 2025, medication technicians were absent and caregivers dispensed medications incorrectly, with staff being late on reordering medications. The investigation included interviews and record reviews but found no evidence to support the allegations.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Medication administration records and staff training were reviewed, and no deficiencies were cited. The allegation was determined to be unsubstantiated.
Report Facts
Facility capacity: 175
Census: 84
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ryan Nakao | Administrator/Executive Director | Met with Licensing Program Analyst and administered medications during staff shortage |
| Christina Valerio | Licensing Program Analyst | Conducted complaint investigation and authored report |
| Kimberly Viarella | Licensing Program Analyst | Interviewed staff and cited facility for a similar incident in October 2025 |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 175
Deficiencies: 0
Date: Feb 11, 2026
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2025-07-07 regarding unqualified staff dispensing medication, improper medication administration, and medication management issues at the facility.
Complaint Details
The complaint alleged that unqualified staff dispensed medications, medications were not dispensed as prescribed, and medications were not properly managed. The complaint was found to be unsubstantiated after investigation.
Findings
The investigation found that on July 4, 2025, a medication technician called out, leading to caregivers administering medications. Review of records showed medications were administered by trained staff or an outside company, with no evidence of incorrect or late medication administration. The allegations were unsubstantiated due to lack of preponderance of evidence, and no deficiencies were cited.
Report Facts
Capacity: 175
Census: 84
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ryan Nakao | Administrator/Executive Director | Met with Licensing Program Analyst and administered medications during staff shortage |
| Christina Valerio | Licensing Program Analyst | Conducted complaint investigation and authored report |
| Kimberly Viarella | Licensing Program Analyst | Interviewed staff and cited facility for similar incident in prior inspection |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 175
Deficiencies: 0
Date: Feb 4, 2026
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that the facility staff do not ensure the facility is cleaned properly, including claims that garbage cans were left in hallways, vacuuming was not done, and walls were greasy.
Complaint Details
The complaint was unsubstantiated based on observations and interviews. No deficiencies were cited under California Code of Regulations Title 22, Division 6, Chapter 8.
Findings
The investigation found that housekeeping staff were observed cleaning bedrooms, carpets, and hallways with no garbage in hallways and no greasy walls. Most bedrooms were clean and odor-free, with one room having a distinct bodily fluid smell but was cleaned regularly. Overall, there was no preponderance of evidence to substantiate the complaint.
Report Facts
Capacity: 175
Census: 84
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christina Valerio | Licensing Program Analyst | Conducted the complaint investigation |
| Ryan Nakao | Administrator | Facility administrator met with evaluator during investigation |
| Stephen Richardson | Supervisor | Supervisor named in report |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 175
Deficiencies: 0
Date: Feb 4, 2026
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that the facility staff do not ensure the facility is cleaned properly, including claims that garbage cans were left in hallways, vacuuming was not done, and walls were greasy.
Complaint Details
The complaint was unsubstantiated based on observations and interviews. There was no preponderance of evidence to prove the allegation occurred.
Findings
The investigation found that housekeeping staff were observed cleaning bedrooms, carpets, and hallways, with no garbage in hallways and no greasy walls. Most bedrooms were clean and odor-free, with one room having a distinct bodily fluid smell but was cleaned regularly. The allegation was determined to be unsubstantiated with no deficiencies cited.
Report Facts
Capacity: 175
Census: 84
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christina Valerio | Licensing Program Analyst | Conducted the complaint investigation |
| Ryan Nakao | Administrator | Facility administrator met during investigation |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 175
Deficiencies: 0
Date: Jan 26, 2026
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations that staff did not administer medication to a resident and failed to order residents' medications in a timely manner.
Complaint Details
The complaint was unsubstantiated. Allegations included failure to administer medication and failure to order medications timely. The investigation found no preponderance of evidence to prove the allegations occurred.
Findings
The investigation reviewed medication administration records and correspondence for four residents. Although some medication charting was late and there were instances of unavailable medication, the evidence was insufficient to substantiate the allegations. No deficiencies were cited and the complaint was determined to be unsubstantiated.
Report Facts
Residents reviewed: 4
Medication signature missing dates: 5
Capacity: 175
Census: 86
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christina Valerio | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Ryan Nakao | Administrator | Facility administrator met during the investigation and involved in addressing medication issues |
Inspection Report
Monitoring
Census: 86
Capacity: 175
Deficiencies: 0
Date: Jan 26, 2026
Visit Reason
The visit was an unannounced quarterly case management visit conducted to ensure compliance with a probationary license due to a Stipulation Waiver and Order effective November 14, 2025.
Findings
The facility was observed to be clean, safe, and in good repair with no odors or health and safety issues noted. The stipulation was posted as required, personnel records were updated, and required documents were submitted on time. Monthly staff training on Title 22 regulations was provided.
Report Facts
Capacity: 175
Census: 86
Training dates: Monthly training provided on 11/27, 12/23, and 01/15/2026
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ryan Nakao | Administrator | Met with Licensing Program Analyst and mentioned in personnel records observation |
| Christina Valerio | Licensing Program Analyst | Conducted the inspection visit |
| Stephen Richardson | Licensing Program Manager | Named in report header and signature section |
Inspection Report
Monitoring
Census: 86
Capacity: 175
Deficiencies: 0
Date: Jan 26, 2026
Visit Reason
The visit was an unannounced quarterly case management visit conducted to ensure compliance with a probationary license due to a Stipulation Waiver and Order effective November 14, 2025.
Findings
The facility was observed to be clean, safe, sanitary, and in good repair with no odors. The stipulation was posted conspicuously, incident reports were received, and personnel records were updated. No health or safety issues were noted during observations of resident rooms and common areas.
Report Facts
Capacity: 175
Census: 86
Training dates: Monthly training provided on 11/27, 12/23, and 01/15/2026
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ryan Nakao | Administrator | Met with Licensing Program Analyst during inspection and noted for updating personnel records |
| Christina Valerio | Licensing Program Analyst | Conducted the inspection visit |
| Stephen Richardson | Licensing Program Manager | Named in report header and signature |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 175
Deficiencies: 0
Date: Jan 26, 2026
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations that staff did not administer medication to a resident and failed to order residents' medications in a timely manner.
Complaint Details
The complaint alleged that staff did not administer medication to a resident for two days and failed to order medications timely, with the reporting party stating this was the seventh occurrence. The investigation found no preponderance of evidence to prove the allegations, resulting in an unsubstantiated finding.
Findings
The investigation reviewed medication administration records and correspondence for four residents. Although some medication charting was late and there were instances of unavailable medication, the evidence was insufficient to substantiate the allegations. The complaint was determined to be unsubstantiated with no deficiencies cited.
Report Facts
Resident records reviewed: 4
Medication missing signature dates: 5
Medication availability issues: 3
Complaint receipt date: Sep 24, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christina Valerio | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Ryan Nakao | Administrator | Facility administrator met with investigator and was involved in addressing medication issues |
| Stephen Richardson | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 175
Deficiencies: 1
Date: Jan 22, 2026
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2025-05-28 regarding staff not ensuring a resident was assisted with glucose testing and allegations related to nourishment and hydration.
Complaint Details
The complaint investigation was substantiated for the allegation that staff did not ensure the resident was assisted with glucose testing. The allegations that staff did not ensure adequate nourishment and sufficient beverages resulting in malnutrition and dehydration were unsubstantiated.
Findings
The investigation substantiated that staff failed to ensure a resident's blood glucose was checked as ordered, posing an immediate health and safety risk. However, allegations related to inadequate nourishment and hydration were unsubstantiated due to insufficient evidence. A plan of correction was implemented and cleared during the visit.
Deficiencies (1)
Licensee did not ensure resident's blood glucose level was checked by staff at 8:00 AM on April 26th and 27th, 2025, posing an immediate health, safety, and personal rights risk.
Report Facts
Facility Capacity: 175
Census: 86
Deficiencies cited: 1
Plan of Correction Due Date: 2026
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ryan Nakao | Administrator | Met with Licensing Program Analyst during complaint investigation |
| Christina Valerio | Licensing Program Analyst | Conducted the complaint investigation |
| Stephen Richardson | Supervisor | Supervisor overseeing the complaint investigation |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 175
Deficiencies: 1
Date: Jan 22, 2026
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2025-05-28 regarding staff not ensuring a resident was assisted with glucose testing and allegations related to nourishment and hydration.
Complaint Details
The complaint investigation was substantiated for the allegation that staff did not ensure the resident was assisted with glucose testing. The allegation regarding inadequate nourishment and hydration was unsubstantiated. Appeal rights were provided and an exit interview was conducted.
Findings
The investigation substantiated that staff failed to assist a resident with glucose testing, missing blood sugar checks on specific dates, posing health and safety risks. Another allegation regarding inadequate nourishment and hydration was unsubstantiated due to insufficient evidence. A plan of correction was implemented and cleared during the visit.
Deficiencies (1)
Licensee did not ensure resident's blood glucose level was checked by staff at 8:00 AM on April 26th and 27th, 2025.
Report Facts
Facility capacity: 175
Resident census: 86
Deficiency count: 1
Plan of Correction due date: Jan 23, 2026
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christina Valerio | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Ryan Nakao | Administrator | Facility administrator met during investigation and named in findings |
| Stephen Richardson | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Capacity: 175
Deficiencies: 0
Date: Jan 9, 2026
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that the facility did not follow proper food safety policies, specifically allowing dairy products and juice to sit out for hours before breakfast service.
Complaint Details
The complaint alleged improper food safety practices by allowing dairy products and juice to sit out for hours before breakfast. The allegation was unsubstantiated based on observations, interviews, and evidence collected.
Findings
After multiple unannounced visits and review of photographic evidence, the Licensing Program Analyst observed proper food safety practices including food items being kept on ice, kitchen cleanliness, and staff holding up-to-date Food Handler certificates. Interviews with staff and residents revealed no concerns. The allegation was determined to be unsubstantiated with no deficiencies cited.
Report Facts
Facility capacity: 175
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christina Valerio | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Ryan Nakao | Administrator | Facility administrator met with Licensing Program Analyst during investigation |
| Stephen Richardson | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Capacity: 175
Deficiencies: 0
Date: Jan 9, 2026
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation received on 2025-12-31 that the facility did not follow proper food safety policies, specifically allowing dairy products and juice to sit out for hours before breakfast service.
Complaint Details
The complaint alleged improper food safety practices by allowing dairy products and juice to sit out for hours before breakfast. The allegation was unsubstantiated based on observations, interviews, and evidence collected during the investigation.
Findings
After multiple unannounced visits and review of photographic evidence, the Licensing Program Analyst observed that food safety protocols were followed, including proper storage of dairy products on ice and staff holding valid Food Handler certificates. Interviews with staff and residents revealed no concerns. The allegation was determined to be unsubstantiated with no deficiencies cited.
Report Facts
Facility capacity: 175
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christina Valerio | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Ryan Nakao | Administrator | Facility administrator met during the investigation |
| Stephen Richardson | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 175
Deficiencies: 0
Date: Jan 6, 2026
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 2025-04-16 regarding staff treatment of residents, care provision when clearing call buttons, staff physical capability, scheduled showers, and staff response to call buttons.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included disrespectful treatment of residents, failure to provide care when clearing call buttons, staff physical incapability, missed scheduled showers, and failure of staff to respond to call buttons in assigned areas. No deficiencies were cited.
Findings
After interviews with residents, staff, and review of facility files, the allegations were found to be unsubstantiated due to lack of preponderance of evidence. Residents generally reported respectful treatment and call lights being answered, though some staff had been written up for delayed call light responses. The facility had a shower schedule but lacked a tracking system. Staff on modified duty worked within their capabilities.
Report Facts
Capacity: 175
Census: 90
Number of residents interviewed: 4
Number of residents interviewed: 5
Staff write-up date: Feb 25, 2025
Call light response time: 15
Call light response delay: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christina Valerio | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Ryan Nakao | Administrator | Facility administrator interviewed during investigation |
| Brian Walgenbach | Licensee | Met with Licensing Program Analyst during investigation |
| Stephen Richardson | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 175
Deficiencies: 1
Date: Jan 6, 2026
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that facility staff were not dispensing medication as prescribed.
Complaint Details
The complaint alleged that facility staff were not dispensing medication as prescribed, including an incident where a staff member attempted to provide incorrect medications to a resident and failure to follow orders for diabetes and blood pressure management. The complaint was substantiated based on interviews, documentation review, and observed missing medication administration signatures.
Findings
The investigation substantiated that medication errors occurred, including staff mixing up medications for residents and missing signatures on medication administration records. These deficiencies posed immediate health, safety, and personal rights risks to residents.
Deficiencies (1)
Failure to assist residents with self-administered medications as required, evidenced by incomplete medication orders for residents R1, R2, and R3.
Report Facts
Capacity: 175
Census: 90
Medications with missing signatures: 5
POC Due Date: Jan 7, 2026
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christina Valerio | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Brian Walgenbach | Facility representative met during the investigation | |
| Stephen Richardson | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 175
Deficiencies: 1
Date: Jan 6, 2026
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that facility staff were not dispensing medication as prescribed.
Complaint Details
The complaint was substantiated. Allegations included staff not dispensing medication as prescribed, mixing up medications for residents, and failure to follow orders for diabetes and blood pressure management.
Findings
The investigation substantiated that a staff member mixed up medications for two residents and that multiple medication administration records (EMAR) had missing signatures, indicating incomplete medication administration and blood sugar monitoring. This posed an immediate health, safety, and personal rights risk to residents.
Deficiencies (1)
Failure to assist residents with self-administered medications as required, evidenced by incomplete medication orders and missing signatures on EMARs for multiple residents.
Report Facts
Capacity: 175
Census: 90
Medications with missing signatures: 5
Missing medication signatures: 4
Missing blood pressure checks: 3
Missing blood sugar check entries: 8
Missing blood sugar check entries: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christina Valerio | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Brian Walgenbach | Licensee | Met with Licensing Program Analyst during the investigation |
| Stephen Richardson | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 175
Deficiencies: 0
Date: Jan 6, 2026
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2025-04-16 regarding staff treatment of residents, care provision when clearing call buttons, staff physical capability, scheduled showers, and staff response to call buttons.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff not treating residents with respect, failure to provide care when clearing call buttons, staff physical incapability, residents missing scheduled showers, and staff not responding to call buttons in assigned areas. Investigations included interviews with residents, staff, and administrator, and review of facility files and resident council minutes. No evidence supported the allegations sufficiently to substantiate them.
Findings
Based on interviews, document reviews, and staff discussions, the allegations were found to be unsubstantiated due to lack of preponderance of evidence. Residents generally reported respectful treatment and call light responses, and staff were found to be working within capabilities. No deficiencies were cited.
Report Facts
Facility capacity: 175
Census: 90
Number of residents interviewed: 4
Number of residents interviewed: 5
Staff write-up date: Feb 25, 2025
Call light response time: 15
Call light delayed response: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christina Valerio | Licensing Program Analyst | Conducted the complaint investigation |
| Ryan Nakao | Administrator | Facility administrator interviewed during investigation |
| Brian Walgenbach | Licensee met during investigation | |
| Stephen Richardson | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 175
Deficiencies: 0
Date: Dec 15, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by multiple allegations received on 2025-02-13 concerning questionable death, staff misconduct including yelling at residents, inappropriate handling, substance use, sexual activities, and call button access issues.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included questionable death, staff yelling at residents, inappropriate handling, staff under influence of drugs/alcohol, staff engaging in sexual activities in presence of residents, delayed response to call buttons, and hiding residents' call buttons. Multiple interviews and record reviews were conducted. No deficiencies were cited.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. The questionable death was due to natural causes with no evidence of mishandling. Allegations of staff yelling, substance use, sexual activities, delayed call button responses, and hiding call buttons were unsubstantiated based on interviews, record reviews, and observations.
Report Facts
Call lights answered over 15 minutes: 11
Facility capacity: 175
Facility census: 89
Resident age: 101
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ryan Nakao | Administrator | Facility administrator met during the investigation and exit interview. |
| Christina Valerio | Licensing Program Analyst | Lead evaluator conducting the complaint investigation. |
| Kimberly Viarella | Licensing Program Analyst | Investigator involved in the complaint investigation. |
| Vincent Moleski | Licensing Program Analyst | Investigator involved in the complaint investigation. |
| Stephen Richardson | Supervisor | Supervisor overseeing the complaint investigation. |
Inspection Report
Capacity: 175
Deficiencies: 0
Date: Dec 3, 2025
Visit Reason
The purpose of this office meeting was to discuss the Stipulation and Waiver for the facility and the Decision and Order that went into effect on 11/14/2025, reviewing all applicable regulations and codes.
Findings
No deficiencies were observed or cited at this time. The meeting covered topics including revocation stayed with probation for three years, denial of appeal of a $15,000 civil penalty, and various compliance requirements and waivers.
Report Facts
Civil Penalty Amount: 15000
Probation Period (years): 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ryan Nakao | Executive Director | Facility representative present at the meeting and recipient of report |
| Payam A. Saljoughian | Counsel | Facility licensee representative present at the meeting |
| Brian Walgenbach | Facility licensee representative present at the meeting | |
| Stephen Richardson | Licensing Program Manager | Licensing Program Manager involved in the meeting and report |
| Christina Valerio | Licensing Program Analyst | Licensing Program Analyst involved in the meeting and report |
| Stephenie Doub | Regional Manager | Community Care Licensing Representative present at the meeting |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 175
Deficiencies: 1
Date: Nov 21, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2025-05-01 alleging insufficient staff at the facility.
Complaint Details
The complaint investigation was substantiated. The allegation of insufficient staff was found valid based on interviews, observations, and record reviews. Numerous medication errors and missed doses were documented, linked to inadequate staffing levels. The facility was cited under 22 CCR Section 87411(a).
Findings
The investigation found substantiated evidence of insufficient staffing at the facility, resulting in medication errors, missed or late medication administration, and inadequate documentation in medication administration records. The facility was cited for not having sufficient staff to meet resident needs, creating an immediate health and safety risk.
Deficiencies (1)
Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met, resulting in immediate health, safety, and/or personal rights risk to clients in care.
Report Facts
Facility capacity: 175
Census: 89
Medication missing: 27
Incident reports reviewed: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ryan Nakao | Administrator | Facility administrator interviewed and involved in exit interview |
| Vincent Moleski | Licensing Program Analyst | Evaluator who conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 175
Deficiencies: 4
Date: Oct 14, 2025
Visit Reason
An unannounced case management visit was conducted to address deficiencies observed during complaint investigation #27-AS-20250131102041.
Complaint Details
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.
Findings
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.
Deficiencies (4)
Failure to regularly observe and document changes in resident's physical, mental, emotional, and social functioning.
Executive Director without medication technician training was administering medications in memory care.
Facility personnel were insufficient in number and competence to meet resident needs; specifically, failure to conduct required 2-hour checks on resident.
False claims violation: making or disseminating false or misleading statements regarding the facility or services.
Report Facts
Capacity: 175
Census: 92
Plan of Correction Due Date: Oct 15, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ryan Nakao | Administrator/Director | Met with Licensing Program Analyst during inspection; mentioned in findings related to medication administration and documentation. |
| Kimberly Viarella | Licensing Program Analyst | Conducted the inspection and investigation. |
| Stephen Richardson | Licensing Program Manager | Named as Licensing Program Manager overseeing the inspection. |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 175
Deficiencies: 0
Date: Sep 3, 2025
Visit Reason
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.
Complaint Details
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.
Findings
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.
Report Facts
Temperature reading: 68
Temperature reading: 76
Temperature reading: 70
Facility capacity: 175
Resident census: 89
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Viarella | Licensing Program Analyst | Conducted the complaint investigation |
| Ryan Nakao | Administrator / Executive Director | Met with Licensing Program Analyst during investigation and involved in decision-making regarding resident relocation |
| Stephen Richardson | Licensing Program Manager | Named as Licensing Program Manager on report |
| M1 | Maintenance staff who assessed the air conditioning problem | |
| M2 | Maintenance supervisor who coordinated repair and assisted with temperature readings and caregiver instruction |
Inspection Report
Complaint Investigation
Census: 96
Capacity: 175
Deficiencies: 0
Date: Jul 29, 2025
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that facility staff acted unprofessionally in front of residents.
Complaint Details
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.
Findings
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.
Report Facts
Capacity: 175
Census: 96
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ryan Nakao | Administrator / Executive Director | Met with Licensing Program Analyst during investigation |
| Kimberly Viarella | Licensing Program Analyst | Conducted the complaint investigation |
| Stephen Richardson | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 94
Capacity: 175
Deficiencies: 2
Date: Jul 15, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that staff were not properly trained and that staff mishandled residents' medications.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Staff were not properly trained as 4 out of 4 medication technician files reviewed lacked required documentation for initial and annual training, including 16 hours of hands-on shadowing and First Aid/CPR certifications.
Staff mishandled residents' medications, including incidents where a medication technician gave incorrect medications to residents on multiple occasions.
Report Facts
Capacity: 175
Census: 94
Files reviewed: 4
Medication errors: 2
Plan of Correction Due Date: 2025
Plan of Correction Due Date: 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ryan Nakao | Administrator / Executive Director | Met with Licensing Program Analyst during investigation and provided statements regarding staff training and medication errors. |
| Kimberly Viarella | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Stephen Richardson | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
| S19 | Medication Technician | Staff member involved in medication errors and training deficiencies. |
| S2 | Medication Technician | Staff member whose training records were reviewed and found deficient. |
| S5 | Medication Technician | Staff member whose training records were reviewed and found deficient. |
| S6 | Medication Technician | Staff member whose training records were reviewed and found deficient. |
Inspection Report
Follow-Up
Census: 94
Capacity: 175
Deficiencies: 2
Date: Jul 15, 2025
Visit Reason
The visit was an unannounced case management follow-up conducted after the delivery of findings from a previous complaint investigation.
Complaint Details
This visit followed a previous complaint investigation (#27-AS-20250122143006) during which additional Title 22 violations were observed.
Findings
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.
Deficiencies (2)
Personnel records did not contain all required documentation showing mandated training had been completed in 4 out of 4 files reviewed.
Staff providing care did not receive appropriate first aid training from qualified persons such as the American Red Cross, as required, in 4 out of 4 files reviewed.
Report Facts
Files reviewed: 4
Residents observed: 7
Caregivers observed: 3
Housekeepers observed: 2
Laundry staff observed: 2
Plan of Correction due date: Sep 1, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ryan Nakao | Administrator/Director | Met with Licensing Program Analyst during the visit |
| Kimberly Viarella | Licensing Program Analyst | Conducted the inspection and authored the report |
| Stephen Richardson | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 94
Capacity: 175
Deficiencies: 1
Date: May 1, 2025
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
The facility did not ensure proper assessments of residents' needs were conducted timely and accurately, with incomplete or contradictory evaluation/appraisals for 3 residents.
Report Facts
Resident fall incidents: 13
Staff scheduled per shift: 4
Staff scheduled per shift: 2
Medication technicians scheduled: 3
Medication technicians scheduled: 2
Medication technicians scheduled: 1
Deficiency Plan of Correction due date: 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Viarella | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Stephen Richardson | Licensing Program Manager | Oversaw the complaint investigation report |
| Ryan Nakao | Administrator | Facility administrator interviewed during the investigation |
Inspection Report
Complaint Investigation
Census: 88
Capacity: 175
Deficiencies: 1
Date: Feb 14, 2025
Visit Reason
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.
Complaint Details
The visit was initiated as a complaint investigation but the deficiency found was unrelated to the original complaint. The deficiency involved failure to submit a death report for a resident who died on 01/12/25. No indication was made that the report was sent to the licensing division, and the facility confirmed it was not faxed.
Findings
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 personal rights risk.
Deficiencies (1)
A written report of a resident's death was not submitted to the licensing agency within seven days as required by 22 CCR Section 87211(a)(1)(A).
Report Facts
Capacity: 175
Census: 88
Plan of Correction Due Date: Feb 18, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ryan Nakao | Administrator | Facility administrator met during inspection and named in findings |
| Vincent Moleski | Licensing Program Analyst | Conducted the inspection and cited the deficiency |
| Stephen Richardson | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 88
Capacity: 175
Deficiencies: 1
Date: Feb 14, 2025
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
A written report of a resident's death was not submitted to the licensing agency within seven days as required by 22 CCR Section 87211(a)(1)(A).
Report Facts
Capacity: 175
Census: 88
Plan of Correction Due Date: POC due date is 02/18/2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vincent Moleski | Licensing Program Analyst | Conducted the inspection and identified the deficiency |
| Ryan Nakao | Administrator | Facility administrator met during the inspection and was involved in the exit interview |
| Stephen Richardson | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Annual Inspection
Census: 87
Capacity: 175
Deficiencies: 1
Date: Jan 29, 2025
Visit Reason
An unannounced Case Management visit was conducted on 01/29/2025 to continue the annual inspection of the Golden Pond Retirement Community facility.
Findings
The inspection found that all required employees had appropriate background clearances and medication administration procedures were in compliance. However, a deficiency was cited for failure to respond to a call alert in a memory care resident's room, posing a potential threat to resident health, safety, and personal rights.
Deficiencies (1)
Failure to respond to the call alert activated on 01/28/2025 in a memory care resident's room, posing a potential threat to health, safety, and personal rights of residents.
Report Facts
Plan of Correction Due Date: Feb 26, 2025
Number of employees under age 18: 3
Number of staff files reviewed: 2
Number of resident files reviewed: 2
Number of pagers ordered: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ryan Nakao | Executive Director | Met with Licensing Program Analyst and provided information during inspection |
| Kimberly Viarella | Licensing Program Analyst | Conducted the inspection and file review |
| Stephen Richardson | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Annual Inspection
Census: 87
Capacity: 175
Deficiencies: 1
Date: Jan 29, 2025
Visit Reason
Unannounced Case Management visit was made to continue the annual inspection of the facility.
Findings
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.
Deficiencies (1)
The Licensee did not ensure timely response to a call alert activated in a memory care resident's room, resulting in a potential threat to health, safety, and personal rights of residents.
Report Facts
Deficiency due date: Feb 26, 2025
Staff files reviewed: 2
Resident files reviewed: 2
Pages in Guardian Roster: 41
Pages in LIC 500: 4
Employees under age 18: 3
Inspection start time: 830
Inspection end time: 1700
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ryan Nakao | Executive Director | Met with Licensing Program Analyst during inspection and involved in exit interview |
| Kimberly Viarella | Licensing Program Analyst | Conducted the inspection and authored the report |
| Stephen Richardson | Licensing Program Manager | Supervisor of the inspection |
Inspection Report
Annual Inspection
Census: 87
Capacity: 175
Deficiencies: 0
Date: Jan 28, 2025
Visit Reason
Unannounced annual inspection visit conducted by Licensing Program Analyst Kimberly Viarella to assess compliance with regulations at Golden Pond Retirement Community.
Findings
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.
Report Facts
Residents assisted in memory care during lunch: 8
Residents in memory care: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ryan Nakao | Designated Facility Administrator/Executive Director | Met with Licensing Program Analyst during inspection. |
| Kimberly Viarella | Licensing Program Analyst | Conducted the inspection visit. |
| Stephen Richardson | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 175
Deficiencies: 1
Date: Dec 6, 2024
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Violation of CCR Title 22, 87705 (f)(2) Care of Persons with Dementia: Items such as cigarettes and lighters were not stored inaccessible to residents with dementia, resulting in unsafe conditions.
Report Facts
Civil penalty amount: 15000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Misty Wilson | Director of Care | Met with Licensing Program Analysts during inspection and acknowledged receipt of appeal rights |
| Kevin Gould | Licensing Program Analyst | Conducted the inspection |
| Czarrina A Camilon-Lee | Licensing Program Manager | Named in report |
| Holly Williams | Licensing Program Analyst | Conducted the inspection |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 175
Deficiencies: 1
Date: Dec 6, 2024
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to respond to resident's call pendant in a timely manner, resulting in resident fall and injury.
Report Facts
Civil penalty amount: 9500
Immediate civil penalty amount: 500
Time resident laid on ground: 35
Time delay in response: 94
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Misty Wilson | Director of Care | Met with Licensing Program Analysts during inspection and acknowledged appeal rights. |
| Kevin Gould | Licensing Program Analyst | Conducted the inspection and signed the report. |
| Czarrina A Camilon-Lee | Licensing Program Manager | Named in report as Licensing Program Manager overseeing the inspection. |
Inspection Report
Census: 95
Capacity: 175
Deficiencies: 0
Date: Sep 13, 2024
Visit Reason
The visit was an unannounced case management inspection to confirm immediate exclusion orders for a staff member (S1).
Findings
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.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Misty Wilson | Care Services Director | Met with Licensing Program Analyst during the visit and discussed immediate exclusion order for staff member S1. |
| Vincent Moleski | Licensing Program Analyst | Conducted the unannounced case management visit. |
| Ryan Nakao | Administrator/Director | Named as facility administrator/director. |
Inspection Report
Complaint Investigation
Census: 78
Capacity: 175
Deficiencies: 0
Date: Sep 6, 2024
Visit Reason
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.
Complaint Details
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.
Findings
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.
Report Facts
Census: 78
Total Capacity: 175
Staff interviewed: 7
Residents interviewed: 7
Call light response time range (minutes): 5
Call light response time range (minutes): 28
Observed call light response time range (minutes): 5
Observed call light response time range (minutes): 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Arielle Pascua | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Ryan Nakao | Facility Designated Administrator | Met with Licensing Program Analyst during the investigation |
| Lisa Rios | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 93
Capacity: 175
Deficiencies: 0
Date: May 31, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to an allegation that staff did not keep the facility free of insects.
Complaint Details
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.
Findings
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.
Report Facts
Capacity: 175
Census: 93
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kesha Lewis | Licensing Program Analyst | Conducted the complaint investigation and facility tour |
| Amanda Friedman | Administrator | Facility administrator met with Licensing Program Analyst during the visit |
| Liza King | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Census: 93
Capacity: 175
Deficiencies: 0
Date: May 31, 2024
Visit Reason
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.
Findings
No deficiencies were observed or cited during the visit. The facility is managing the administrator transition with an interim administrator in place.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Friedman | Designated Facility Administrator | Interviewed regarding her departure and transition plans. |
| Misty Wilson | Care Director | Interim Designated Facility Administrator during transition. |
| Kimberly Viarella | Licensing Program Analyst | Conducted the unannounced case management visit. |
| Stephen Richardson | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Annual Inspection
Census: 90
Capacity: 175
Deficiencies: 1
Date: Jan 22, 2024
Visit Reason
The Licensing Program Analyst conducted an unannounced annual inspection to evaluate compliance with regulatory requirements at the Golden Pond Retirement Community Facility.
Findings
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.
Deficiencies (1)
Resident R9 did not have an LIC 602 updated annually, posing a potential health, safety, or personal rights risk.
Report Facts
Resident files reviewed: 10
Staff files reviewed: 10
Staff interviewed: 5
Residents interviewed: 5
Plan of Correction due date: Feb 5, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Friedman | Administrator | Facility administrator met with Licensing Program Analyst during inspection |
| Vincent Moleski | Licensing Program Analyst | Conducted the annual inspection and authored the report |
| Stephen Richardson | Licensing Program Manager | Named as Licensing Program Manager overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 95
Capacity: 175
Deficiencies: 0
Date: Dec 6, 2023
Visit Reason
The inspection was conducted to investigate complaints received on 09/26/2023 regarding questionable death and medication administration at Golden Pond Retirement Community.
Complaint Details
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.
Findings
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.
Report Facts
Capacity: 175
Census: 95
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Gould | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Amanda Friedman | Administrator | Facility administrator met with Licensing Program Analyst during inspection |
| Czarrina A Camilon-Lee | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 95
Capacity: 175
Deficiencies: 1
Date: Dec 6, 2023
Visit Reason
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.
Complaint Details
The visit was complaint-related, focusing on an open complaint regarding missing medication administration documentation. The report does not explicitly state substantiation status.
Findings
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.
Deficiencies (1)
Incidental Medical and Dental Care: The licensee failed to arrange or assist in arranging appropriate medical care as evidenced by missing documentation on resident's MAR for several AM medications on 7/25/23, posing a potential health, safety, and personal rights risk.
Report Facts
Census: 95
Total Capacity: 175
Deficiency Type Count: 1
Plan of Correction Due Date: Dec 29, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Gould | Licensing Program Analyst | Conducted the inspection and cited deficiencies |
| Amanda Friedman | Administrator | Facility administrator met during inspection and discussed investigation details |
| Czarrina A Camilon-Lee | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 95
Capacity: 175
Deficiencies: 1
Date: Dec 6, 2023
Visit Reason
An announced inspection was conducted to address documentation deficiencies related to medication administration as part of an open complaint investigation.
Complaint Details
The visit was complaint-related with an open complaint regarding medication administration documentation. The deficiency was substantiated by missing MAR documentation.
Findings
The inspection found missing documentation on a resident's medication administration record (MAR) dated July 25, 2023, indicating the facility did not follow all aspects of medical care, posing potential health and safety risks to residents.
Deficiencies (1)
Missing documentation of several AM medications administered to a resident on 7/25/23, violating medical and dental care requirements.
Report Facts
Deficiencies cited: 1
Plan of Correction Due Date: Dec 29, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Gould | Licensing Program Analyst | Conducted the inspection and cited deficiencies |
| Amanda Friedman | Administrator | Facility administrator met with LPA during inspection |
| Czarrina A Camilon-Lee | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 99
Capacity: 175
Deficiencies: 0
Date: Nov 8, 2023
Visit Reason
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.
Complaint Details
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.
Findings
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.
Report Facts
Facility capacity: 175
Census: 99
Staff interviews: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Gould | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Tracy McLinn | Administrator | Facility administrator met with Licensing Program Analyst during investigation |
Inspection Report
Follow-Up
Census: 99
Capacity: 175
Deficiencies: 1
Date: Nov 8, 2023
Visit Reason
An unannounced Case Management Deficiencies inspection was conducted to address deficiencies observed during a prior complaint inspection.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to ensure an adequate theft and loss program as specified in Health and Safety Code Section 1569.153, evidenced by lack of documentation of theft/loss incidents since 2014 despite staff statements of more recent missing items.
Report Facts
Capacity: 175
Census: 99
Plan of Correction Due Date: Dec 6, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Friedman | Administrator | Met with Licensing Program Analyst during inspection and discussed findings |
| Kevin Gould | Licensing Program Analyst | Conducted the inspection and staff interviews |
| Czarrina A Camilon-Lee | Licensing Program Manager | Supervisor of the inspection |
Inspection Report
Follow-Up
Census: 99
Capacity: 175
Deficiencies: 1
Date: Nov 8, 2023
Visit Reason
An unannounced Case Management Deficiencies inspection was conducted to address deficiencies observed during a prior complaint inspection at Golden Pond Retirement Community.
Complaint Details
The visit was a follow-up to deficiencies observed during a complaint inspection. The department concluded the facility did not follow their theft loss policy as required.
Findings
The inspection found that the facility failed to maintain adequate documentation of theft and loss incidents since 2014, despite staff interviews confirming missing resident items within the last two years. This failure to follow their own theft loss policy poses potential health, safety, and personal rights risks to residents.
Deficiencies (1)
Failure to ensure an adequate theft and loss program as specified in Health and Safety Code Section 1569.153, evidenced by lack of documentation of theft/loss incidents since 2014 and staff statements indicating more recent missing items.
Report Facts
Capacity: 175
Census: 99
Plan of Correction Due Date: Dec 6, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Gould | Licensing Program Analyst | Conducted the inspection and interviews |
| Amanda Friedman | Administrator | Facility administrator met with the Licensing Program Analyst during the inspection |
Inspection Report
Census: 95
Capacity: 175
Deficiencies: 0
Date: Oct 17, 2023
Visit Reason
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.
Findings
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.
Report Facts
Capacity: 175
Census: 95
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Friedman | Administrator | Facility representative met during inspection and involved in compliance discussions |
| Brian Walgenbach | Licensee | Facility representative involved in compliance discussions |
| Joel Goldman | Attorney | Facility representative involved in compliance discussions |
| Kevin Gould | Licensing Program Analyst | Department representative conducting the inspection |
| Czarrina A Camilon-Lee | Licensing Program Manager | Department representative conducting the inspection |
| Kim Viarella | Licensing Program Analyst | Department representative conducting the inspection |
| Stephen Richardson | Licensing Program Manager | Department representative conducting the inspection |
| Stephenie Doub | Regional Manager | Department representative conducting the inspection |
Inspection Report
Complaint Investigation
Census: 99
Capacity: 175
Deficiencies: 2
Date: Oct 3, 2023
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Administrator failed to demonstrate adequate knowledge of regulatory requirements and to ensure safeguarding dementia resident R1 from having access or possession of cigarettes and proper oversight of supervision for R1's smoking.
Facility staff failed to adequately supervise and monitor R1’s activity on 12/26/22.
Report Facts
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Gould | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Czarrina A Camilon-Lee | Licensing Program Manager | Supervisor overseeing the inspection. |
| Amanda Friedman | Administrator | Facility administrator at time of incident, named in findings related to failure to safeguard resident. |
Inspection Report
Plan of Correction
Census: 99
Capacity: 175
Deficiencies: 0
Date: Oct 3, 2023
Visit Reason
An unannounced Plan of Correction (POC) inspection was conducted to ensure all components of the plan of correction had been completed.
Findings
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.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Gould | Licensing Program Analyst | Conducted the Plan of Correction inspection |
| Amanda Friedman | Facility Administrator met during the inspection | |
| Czarrina A Camilon-Lee | Licensing Program Manager | Named in the report header |
Inspection Report
Complaint Investigation
Census: 97
Capacity: 175
Deficiencies: 1
Date: Sep 26, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that facility staff did not keep current and complete resident records.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Resident Records. A separate, complete, and current record shall be maintained for each resident in the facility, readily available to facility staff and to licensing agency staff and shall contain specified information. This requirement was not met as evidenced by statements obtained and staff notes indicating staff could not locate the correct forms to provide to emergency responders in a timely manner and when located the documents provided were not up to date or reflect the wishes of the residents.
Report Facts
Capacity: 175
Census: 97
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Gould | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Amanda Friedman | Administrator | Facility administrator met during the investigation |
| Czarrina A Camilon-Lee | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 99
Capacity: 175
Deficiencies: 1
Date: Jun 29, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation of questionable death received on 2022-12-29.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Care of Persons with Dementia: Items such as cigarettes were not stored inaccessible to residents with dementia, resulting in injury and death.
Report Facts
Capacity: 175
Census: 99
Plan of Correction Due Date: Jun 30, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Gould | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Czarrina A Camilon-Lee | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 103
Capacity: 175
Deficiencies: 3
Date: Mar 30, 2023
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (3)
Fire Safety: Facility knowingly violated fire clearance by allowing resident to smoke on their balcony, not in a designated area, resulting in a fire and posing immediate health, safety, and personal rights risks to residents.
Personal Rights: Facility allowed resident to smoke on balcony and start a fire, posing personal rights risk to resident safety and health.
Administrator Qualifications and Duties: Administrator knowingly allowed resident to smoke in non-designated area violating fire clearance, resulting in fire and potential health, safety, and personal rights risks.
Report Facts
Facility Capacity: 175
Census: 103
Plan of Correction Due Date: 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Gould | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Tracy McLinn | Administrator | Facility administrator involved in findings related to fire clearance and smoking violations |
| Czarrina A Camilon-Lee | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 103
Capacity: 175
Deficiencies: 0
Date: Mar 30, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation of cockroach infestation at Golden Pond Retirement Community.
Complaint Details
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.
Findings
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.
Report Facts
Capacity: 175
Census: 103
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Gould | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Tracy McLinn | Administrator | Facility administrator met during inspection and exit interview |
Inspection Report
Complaint Investigation
Census: 105
Capacity: 175
Deficiencies: 2
Date: Mar 22, 2023
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Facility staff failed to check on call light after resident fell and sustained an injury resulting in a delay in treatment.
Staff failure to respond to call pendant when resident needed assistance going to the bathroom which resulted in resident falling and sustaining a hip fracture.
Report Facts
Census: 105
Total Capacity: 175
Call pendant response delay (minutes): 84
Resident on ground duration (minutes): 35
Deficiency due date: Mar 23, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Gould | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Tracy McLinn | Administrator | Facility administrator met with Licensing Program Analyst during investigation |
| Czarrina A Camilon-Lee | Licensing Program Manager | Oversaw licensing program and signed report |
Inspection Report
Annual Inspection
Census: 107
Capacity: 175
Deficiencies: 1
Date: Jan 10, 2023
Visit Reason
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.
Findings
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.
Deficiencies (1)
Three out of nine staff files did not have current first aid certificates, posing an immediate health, safety, or personal rights risk to persons in care.
Report Facts
Residents in memory care: 24
Staff files reviewed: 9
Resident files reviewed: 11
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tracy McLinn | Administrator | Met with Licensing Program Analyst during inspection and involved in facility tour |
| Kevin Gould | Licensing Program Analyst | Conducted the inspection and authored the report |
| Czarrina A Camilon-Lee | Licensing Program Manager | Named as Licensing Program Manager overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 108
Capacity: 175
Deficiencies: 1
Date: Dec 27, 2022
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to ensure that a resident with dementia had an updated annual medical assessment and reappraisal as required, posing an immediate safety risk.
Report Facts
Capacity: 175
Census: 108
Deficiency count: 1
Plan of Correction Due Date: Dec 28, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Albert Johnson | Licensing Program Analyst | Conducted the case management visit and cited deficiency |
| Stephenie Doub | Licensing Program Manager | Supervisor overseeing the inspection |
| Tracy McLinn | Administrator | Facility administrator met during the visit |
Inspection Report
Complaint Investigation
Census: 110
Capacity: 175
Deficiencies: 0
Date: Nov 4, 2022
Visit Reason
Unannounced complaint investigation visit conducted to investigate allegations of staff showing inappropriate content and making inappropriate sexual advances to a resident in care.
Complaint Details
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.
Findings
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.
Report Facts
Capacity: 175
Census: 110
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Gould | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Tracy McLinn | Administrator | Facility administrator met with Licensing Program Analyst during inspection |
| Czarrina A Camilon-Lee | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 110
Capacity: 175
Deficiencies: 0
Date: Nov 4, 2022
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that the facility directed staff to come to work with an infectious condition.
Complaint Details
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.
Findings
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.
Report Facts
Complaint Control Number: 27-AS-20220808094023
Number of staff interviewed: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Gould | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Brian Walgenbach | Administrator | Facility administrator met with Licensing Program Analyst to discuss investigation details |
| Czarrina A Camilon-Lee | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Plan of Correction
Capacity: 175
Deficiencies: 0
Date: Jul 29, 2022
Visit Reason
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.
Findings
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.
Report Facts
Capacity: 175
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Gould | Licensing Program Analyst | Conducted the Plan of Correction inspection and confirmed completion of POCs |
| Brian Walgenbach | Administrator | Facility administrator named in the report header |
Inspection Report
Complaint Investigation
Census: 114
Capacity: 175
Deficiencies: 0
Date: May 6, 2022
Visit Reason
Unannounced complaint investigation visit conducted to investigate allegations related to staff failing to meet resident's needs and violating resident's personal rights.
Complaint Details
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.
Findings
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.
Report Facts
Capacity: 175
Census: 114
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Gould | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Czarrina A Camilon-Lee | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 114
Capacity: 175
Deficiencies: 1
Date: May 6, 2022
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
The licensee failed to assist residents with self-administered medications as needed, specifically administering blood glucose testing and insulin after the resident had started eating, violating physician instructions.
Report Facts
Capacity: 175
Census: 114
Plan of Correction Due Date: May 9, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Gould | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Czarrina A Camilon-Lee | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Census: 110
Capacity: 175
Deficiencies: 0
Date: Apr 1, 2022
Visit Reason
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.
Findings
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.
Report Facts
Facility capacity: 175
Census: 110
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tracy McLinn | Administrator | Newly appointed administrator met during the visit |
| Kevin Gould | Licensing Program Analyst | Conducted the visit and evaluation |
| Czarrina A Camilon-Lee | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 110
Capacity: 175
Deficiencies: 1
Date: Apr 1, 2022
Visit Reason
The inspection visit was conducted to address an incident report regarding a resident elopement that occurred on 2022-03-27.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Care of Persons with Dementia: Facility staff failed to ensure the continued safety of residents if they wander away from the facility, evidenced by R1's elopement without staff knowledge or supervision for over 24 hours.
Report Facts
Census: 110
Total Capacity: 175
Deficiency count: 1
Plan of Correction Due Date: Apr 4, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Gould | Licensing Program Analyst | Conducted the inspection and cited the deficiency |
| Tracy McLinn | Administrator | Met with Licensing Program Analyst during inspection; newly appointed administrator |
| Czarrina A Camilon-Lee | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 102
Capacity: 175
Deficiencies: 1
Date: Mar 24, 2022
Visit Reason
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.
Complaint Details
The visit was complaint-related, investigating medication errors on R1's medication administration logs. The complaint was substantiated based on observations and staff statements.
Findings
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.
Deficiencies (1)
Medication staff had not documented medications administered to R1 according to the facility plan of operations, posing an immediate health, safety, and personal rights risk to residents.
Report Facts
Census: 102
Total Capacity: 175
Deficiency Type Count: 1
Plan of Correction Due Date: Mar 25, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Gould | Licensing Program Analyst | Conducted the case management inspection and cited deficiencies |
| Tracy McGlinn | Administrator | Met with Licensing Program Analyst during inspection |
| Czarrina A Camilon-Lee | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Annual Inspection
Capacity: 175
Deficiencies: 0
Date: Feb 23, 2022
Visit Reason
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.
Findings
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.
Report Facts
Water temperature: 112
Resident files reviewed: 5
Staff files reviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Gould | Licensing Program Analyst | Conducted the inspection and evaluation |
| Misty Wilson | Interim Administrator | Met with Licensing Program Analyst and participated in facility tour |
Inspection Report
Capacity: 175
Deficiencies: 0
Date: Jan 7, 2022
Visit Reason
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.
Findings
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.
Report Facts
Capacity: 175
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anthony Tuck | Licensing Program Analyst | Conducted the case management visit and inspection |
| Lupe Ramirez | Executive Director | Met with Licensing Program Analyst during the visit and provided information |
Inspection Report
Complaint Investigation
Census: 103
Capacity: 175
Deficiencies: 0
Date: Nov 24, 2021
Visit Reason
An unannounced case management inspection was conducted to address concerns regarding a self-reported theft of a resident's valuables.
Complaint Details
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.
Findings
No deficiencies were observed or cited during the inspection. The department will continue to investigate the case, and the case management remains open.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Gould | Licensing Program Analyst | Conducted the inspection and interviews related to the complaint. |
| Lupe Ramirez | Administrator | Met with the Licensing Program Analyst to discuss steps taken to address the resident's concerns. |
Inspection Report
Complaint Investigation
Census: 103
Capacity: 175
Deficiencies: 0
Date: Oct 13, 2021
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that facility staff were interfering with a resident's medical treatment.
Complaint Details
The complaint alleged that facility staff were interfering with a resident's medical treatment. The investigation concluded the allegation was unfounded and dismissed.
Findings
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.
Report Facts
Capacity: 175
Census: 103
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Gould | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Stephen Sarine | Administrator | Facility administrator met during the investigation |
Inspection Report
Annual Inspection
Census: 97
Capacity: 175
Deficiencies: 0
Date: Aug 26, 2021
Visit Reason
The inspection was conducted as a required 1 year annual inspection to evaluate the facility's compliance with health and safety regulations.
Findings
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.
Report Facts
Water temperature: 116
Water temperature: 108
Capacity: 175
Census: 97
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Gould | Licensing Program Analyst | Conducted the inspection and evaluation |
| Jessica Rivera | Facility staff who met with the Licensing Program Analyst during the inspection | |
| Stephen Sarine | Administrator | Facility administrator involved in the inspection |
Inspection Report
Complaint Investigation
Census: 93
Capacity: 175
Deficiencies: 0
Date: May 21, 2021
Visit Reason
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.
Complaint Details
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.
Findings
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.
Report Facts
Capacity: 175
Census: 93
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Pheej Cheng | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Guadelupe Ramirez | Administrator | Met with Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 133
Capacity: 175
Deficiencies: 0
Date: May 8, 2021
Visit Reason
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.
Complaint Details
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.
Findings
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.
Report Facts
Capacity: 175
Census: 133
Complaint Control Number: 27-AS-20200619102551
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Reber | Evaluator / Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Alycia Berryman | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Jessica Rivera | Facility staff member met with during the investigation | |
| Stephen Sarine | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 95
Capacity: 175
Deficiencies: 0
Date: Feb 10, 2021
Visit Reason
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.
Complaint Details
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.
Findings
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.
Report Facts
Capacity: 175
Census: 95
Copies of report: 2
Copies of report: 1
Copies of report: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mai Thao | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Lupe Ramirez | Administrator | Interviewed during investigation and recipient of report copies |
| Stephen Sarine | Administrator | Named as facility administrator in report header |
Report
October 14, 2025
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August 25, 2025
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