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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347000985
Report Date: 08/12/2020
Date Signed: 08/12/2020 04:57:35 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:GOLDEN POND RETIREMENT COMMUNITYFACILITY NUMBER:
347000985
ADMINISTRATOR:STEPHEN SARINEFACILITY TYPE:
740
ADDRESS:3415 MAYHEW ROADTELEPHONE:
(916) 369-8967
CITY:SACRAMENTOSTATE: CAZIP CODE:
95827
CAPACITY:175CENSUS: DATE:
08/12/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Administator Guadalupe RamirezTIME COMPLETED:
03:30 PM
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On 08/12/2020 Licensing Program Analysts (LPAs) McCrory and Wolter contacted the facility Administrator (Admin) Guadalupe "Lupe" Ramirez to commence a Case Management Visit via phone due to COVID-19 and pre-cautionary measures. LPAs discussed the purpose of the call was to obtain further information on the LIC 624 Unusual Incident/Injury Report received 08/05/2020.

During the call the following information was obtained from Admin:
  1. R1 is an Independent Facility Resident.
  2. R1 is still in hospital and has a rehabilitation services referral, however R1 wants to return to facility.
  3. R1 will be visited by Facility's Direct Care Coordinator to be reassessed .
LPA McCrory requested notification when R1 returns to the facility and a copy of the updated LIC 602A Physician's Report.

On 08/05/2020 Licensing Program Analyst (LPA) McCrory received a LIC 624 Unusual Incident/Injury Report regarding a Resident (R1) unable to stand on feet on 08/02/2020 and paramedics taking resident to local hospital .

On 08/07/2020 email received from Admin stated the following:
  1. R1 is independent with ADLs.
  2. Staff assists with bed, trash, and dishes.
  3. Meals are "to-go" due to COVID-19 Pandemic


No deficiencies are cited at this time.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jasmine McCroryTELEPHONE: (916) 214-5020
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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