345002876-4-16-2026-59-AS-LMUZ-DU2QK3-20260513121336

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 345002876
Report Date: 04/16/2026
Date Signed: 04/16/2026 02:47:39 PM

Unsubstantiated

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
02/23/2026 and conducted by Evaluator Michael Hood

COMPLAINT CONTROL NUMBER: 59-AS-20260223091811

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:	04/16/2026
		UNANNOUNCED	TIME BEGAN:	01:25 PM
MET WITH:	Stephanie Harmon-Christensen, House Manager		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Questionable Death.

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

Allegation: Questionable death.

Relevant party reported that to the Department concerns regarding the passing of resident (R1), who may have experienced medication mismanagement at the facility that contributed to their passing.

** Report continued on 9099-C **

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:	DATE: 04/16/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2026

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-20260223091811

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: 04/16/2026

NARRATIVE

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Death Report LIC 624A submitted to the Department regarding R1's death states R1 passed away on February 10, 2026. Death report states "county called [spouse], who shared with [staff] that they refused to do an autopsy. They told [spouse] sense [R1's] airways were cleared, there was no need to do an autopsy." On April 2, 2026, the Department obtained R1's death certificate by mail. R1’s date of death is listed as February 10, 2026. R1's immediate cause of death is listed as cardiopulmonary arrest, with the time interval between the onset and death noted in minutes. The underlying conditions contributing to R1’s death are a history of ischemic stroke, with the time interval between the onset and death noted in months. No other significant conditions contributed to R1’s death. R1’s death was reported to the Sacramento County Coroner’s office and no biopsy or autopsy was performed.

On January 14, 2026, LPA conducted a medication count for R1, comparing R1's Centrally Stored Medication Form (CSMF) and Medication Administration Record (MAR) with medications centrally stored for the resident. LPA did not observe any evidence of R1 missing medications. LPA requested medications records from January 14, 2026 to February 10, 2026. Facility was unable to provide requested medication records to LPA by April 16, 2026. LPA cited facility for records in a separate inspection report conducted on April 16, 2026.

Interview conducted with resident (R2) indicated that they have never witnessed any incidents of residents being neglected at the facility. R2 stated that they have no concerns regarding medication administration at the facility, they feel their care needs are being met at the facility, and they are treated well by facility staff.

Based on interviews conducted, observations, and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegation is found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

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

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:	DATE: 04/16/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2026

LIC9099 (FAS) - (06/04)

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