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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347000985
Report Date: 04/01/2022
Date Signed: 04/01/2022 04:39:43 PM


Document Has Been Signed on 04/01/2022 04:39 PM - It Cannot Be Edited

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:LUPE RAMIREZFACILITY TYPE:
740
ADDRESS:3415 MAYHEW ROADTELEPHONE:
(916) 369-8967
CITY:SACRAMENTOSTATE: CAZIP CODE:
95827
CAPACITY:175CENSUS: 110DATE:
04/01/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Tracy McLinnTIME COMPLETED:
04:45 PM
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On 4/1/22 at 1:30pm Licensing Program Analyst (LPA) Kevin Gould arrived at Golden Pond Retirement Community for the purpose of addressing the current status of the facility administrator. LPA met with newly appointed administrator Tracy McLinn, who has yet to be confirmed by the department.

LPA inquired as to the status of the facility Administrator position as the administrator submitted for approval does not currently meet all requirements to be confirmed by the department. LPA was informed that the one of the current owners has agreed to appoint himself as the administrator. LPA confirmed the individual has a current administrator certificate and would meet all education and experience requirements required to be appointed to a facility with a capacity of 175 residents.

LPA requested that all documents, LIC 200, LIC 501, current administrator certificate, proof of education requirements and LIC 308. LPA informed the facility to have all documents submitted for approval by Monday, 4/4/22.

There were no deficiencies cited per title 22 regulations. An exit interview was conducted a copy of this report was left at the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 04/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/01/2022
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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