345002876-4-9-2026-59-AS-LCRR-DTLM9V-20260429092523

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 345002876
Report Date: 04/09/2026
Date Signed: 04/09/2026 04:10:09 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/17/2026 and conducted by Evaluator Michael Hood

COMPLAINT CONTROL NUMBER: 59-AS-20260317095212

FACILITY NAME:	GOLDEN MOMENTS CARE HOME WINDING WAY		FACILITY NUMBER:	345002876
ADMINISTRATOR:	DAHLEY, DALEE		FACILITY TYPE:	740
ADDRESS:	4316 ILLINOIS AVENUE		TELEPHONE:	(916) 474-4678
CITY:	FAIR OAKS	STATE: CA	ZIP CODE:	95628
CAPACITY:	6	CENSUS: 1	DATE:	04/09/2026
		UNANNOUNCED	TIME BEGAN:	11:55 AM
MET WITH:	Stephanie Harmon-Christensen, House Manager		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff did not issue a refund to the resident's authorized representative

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Michael Hood arrived at the care home and met with House Manager, Stephanie Harmon-Christensen, to deliver findings regarding the complaint allegation listed above.

During the investigation, LPA conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows:

Allegation: Staff did not issue a refund to the resident's authorized representative

Relevant party reported that resident (R1) resided at the facility and passed away on January 29, 2026. Relevant party reported R1's rent was paid in advance for the month of February, 2026 prior to R1's passing. Relevant party reported that R1's authorized representative did not receive a prorated refund for rent that was paid in advance for the month of February, 2026.
** Report continued on 9099-C **

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:	DATE: 04/09/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20260317095212

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: GOLDEN MOMENTS CARE HOME WINDING WAY	FACILITY NUMBER: 345002876
	VISIT DATE: 04/09/2026

NARRATIVE

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LPA received proof of payment from R1's authorized representative confirming that R1's rent was paid in full from admission date of October 30, 2025, to February 28, 2026. Interview conducted with Licensee on March 24, 2026 indicated that they were not aware whether or not a refund was issued to R1's authorized representative following their passing. Licensee was to provide any information regarding whether refund was issued to R1's authorized representative. As of the April 9, 2026, LPA has not received any information from Licensee regarding refunds issued to R1's authorized representative.

LPA reviewed R1's Admission Agreement signed by R1's authorized representative with an admission date of October 30, 2025, which states "Fees paid in advance will be refunded within 30 days. The total monthly rate set forth in the admission agreement will be prorated on a daily basis upon the resident's admission to, or permanent departure from, the facility during the month. All refunds shall be issued within 30 days...Advance notice to terminate this agreement upon the death of a resident is not required and fees cannot accrue once all personal property belonging to a deceased resident has been removed from the facility. Any agreement to leave personal property must be approved by Administrator (not by caregiving staff)." Per Health and Safety Code §1569.652(c), “A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual, individuals, or entity contractually responsible for the fees or, if the deceased resident paid the fees, to the resident’s estate, within 15 days after the personal property is removed.” Per Title 22, Division 6, Chapter 8, Section 87505(h)(4), “The admission agreement shall not contain the following: Any provision that violates the rights of any residents including but not limited to those specified in Section 87468 and in Health and Safety Code section 1569 et seq.” Interviews conducted with relevant party, house manager, and staff member (S1) indicated that R1's authorized representative removed R1's personal property from the care home on January 29, 2026.

Based on interviews conducted and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per Health and Safety Code, a deficiency is being cited on the attached 9099-D page.

Exit interview was conducted. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:	DATE: 04/09/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2026

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20260317095212

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: GOLDEN MOMENTS CARE HOME WINDING WAY	FACILITY NUMBER: 345002876
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/09/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/24/2026 Section Cited HSC 1569.652(c)	1 2 3 4 5 6 7	§1569.652 Termination of admission agreement upon death of resident; removal of resident’s property; refund of fees paid; notice of contract termination and refunds (c) A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual, individuals, or entity contractually responsible for the fees or, if the deceased resident paid the fees, to the resident’s estate, within 15 days after the personal property is removed. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Facility will refund R1’s authorized representative fees paid from January 30, 2026 to February 28, 2026. Facility will submit proof that refund was issued by POC due date of April 24, 2026.
	8 9 10 11 12 13 14	Based on interviews conducted and records reviewed, the facility did not ensure to issue a refund for advance fees paid to R1’s authorized representative upon the removal of R1’s property after they passed away, which poses a potential health, safety, and/or personal rights risk to the residents in care.	8 9 10 11 12 13 14
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:	DATE: 04/09/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2026

LIC9099 (FAS) - (06/04)

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