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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347000985
Report Date: 07/29/2022
Date Signed: 07/29/2022 11:03:12 AM


Document Has Been Signed on 07/29/2022 11:03 AM - 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:BRIAN WALGENBACHFACILITY TYPE:
740
ADDRESS:3415 MAYHEW ROADTELEPHONE:
(916) 369-8967
CITY:SACRAMENTOSTATE: CAZIP CODE:
95827
CAPACITY:175CENSUS: DATE:
07/29/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Tracy McLinnTIME COMPLETED:
11:30 AM
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On 7/29/22 at 10:45am Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced Plan of Correction (POC) inspection at Golden Pond Retirement Community to review correction from citation from previous inspection. LPA reviewed pending POC and ensured that all had been completed by the licensee.

LPA observed plan of correction have been completed and LPA confirmed all POCs have been completed and meet the agreed stipulations of the plan of correction. LPA reviewed training materials and documentation of staff receiving training.

LPA Gould generated one POC clearance letters during today's inspection and provided to the licensee.

Per California Code of Regulations, Title 22 there were no deficiencies cited during today's inspection. An exit interview was conducted, and 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: 07/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2022
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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