347000985-5-6-2022-27-AS-KHOS-CEANRB-20220510104116

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347000985
Report Date: 05/06/2022
Date Signed: 05/06/2022 03:10:36 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/16/2022 and conducted by Evaluator Kevin Gould

COMPLAINT CONTROL NUMBER: 27-AS-20220216110214

FACILITY NAME:	GOLDEN POND RETIREMENT COMMUNITY		FACILITY NUMBER:	347000985
ADMINISTRATOR:	LUPE RAMIREZ		FACILITY TYPE:	740
ADDRESS:	3415 MAYHEW ROAD		TELEPHONE:	(916) 369-8967
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95827
CAPACITY:	175	CENSUS: 114	DATE:	05/06/2022
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Tracy Mclinn		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Personal Rights:
1) Staff are failing to meet resident's needs
2) Staff are violating resident's personal rights

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kevin Gould made an unannounced inspection to the Golden Pond Retirement Community (RCFE) on 5/6/22 at 1:00pm to conclude the investigation of the above allegations and to deliver the findings. LPA met with Administrator and together discussed the investigation details. LPA conducted additional interview with staff members.

Based on the interviews and statements obtained during the investigation process, the allegations cannot be substantiated because LPA received conflicting statements from both staff, and family members interviewed. The department has determined that although family members provided home made food for a resident, ultimately it is the resident's choice as to what food he or she eats and the resident has the personal rights to eat meals provided by the facility instead of a family member's prepared food. The department and the facility cannot comply with a request that resident only eat food prepared by family members and not facility food.

Report Continued on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2022

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 27-AS-20220216110214

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 COMMUNITY	FACILITY NUMBER: 347000985
	VISIT DATE: 05/06/2022

NARRATIVE

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LPA was also unable to verify that the facility was refusing resident for outings and appointments with family members. LPA was unable to verify a family members presence at the facility and when as the family member was not able to enter the facility and sign in due to COVID restrictions and family members refusal to comply with mitigation measures in place to ensure other resident's safety. Staff interviewed stated that times would be changed last minute and due to resident's needs would need to use the restroom before any outing which could take time and requires two staff to assist the resident. The facility has requested 24 hours notice of any outings or appointments to ensure the staff can ready the resident on time for his outings and appointments.

Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of Personal rights are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed.

There are no deficiencies noted or cited per California Code of Regulations, TITLE 22.

Exit interview was conducted with the facility staff. Appeal Rights were issued, and a copy of this report was left at the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2022

LIC9099 (FAS) - (06/04)

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