347000985-3-22-2023-27-AS-KHOS-CQUJ2K-20230413064003

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347000985
Report Date: 03/22/2023
Date Signed: 03/22/2023 12:08:22 PM

Substantiated

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
11/04/2022 and conducted by Evaluator Kevin Gould

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20221104162120

FACILITY NAME:	GOLDEN POND RETIREMENT COMMUNITY		FACILITY NUMBER:	347000985
ADMINISTRATOR:	TRACY MCLINN		FACILITY TYPE:	740
ADDRESS:	3415 MAYHEW ROAD		TELEPHONE:	(916) 369-8967
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95827
CAPACITY:	175	CENSUS: 105	DATE:	03/22/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Tracy McLinn		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Neglect/Lack of Supervision:
1) Resident sustained a fracture because facility staff did not provide adequate assistance to resident.
2) Staff did not seek medical attention for resident in a timely manner.
3) staff did not respond to call pendant as required.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kevin Gould made an unannounced inspection to Golden Pond Retirement Community on 3/22/23 at 9:00am to conclude the investigation of the above allegations and to deliver the findings. LPA met with Administrator and together discussed the investigation details.

Based on the interviews and statements obtained during the investigation process, the allegations have been corroborated by the department. On 10/10/2022, at 8:58pm, Resident (R1) pressed their call pendant for assistance to the restroom. R1 stated they waited approximately 15 minutes for staff who never arrived. R1 could not wait any longer and attempted to go to the restroom on their own. R1 stood up and sustained an unwitnessed fall and hit his head on an unknown object. Per AlphaOne Ambulance records, they were called at 10:48pm. It is unknown when exactly R1 was found by staff, but staff stated they did call 911 once R1 was found. R1 was on the ground for approximately 35 minutes from the time his pendant was pushed and AlphaOne was called.

Report continued on LIC 9099-C, page 1 of 3.

Substantiated

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: 03/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 4

Control Number 27-AS-20221104162120

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: 03/22/2023

NARRATIVE

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Per call pendant records, R1 pressed their button at 8:58pm and it was manually turned off by staff at
10:22pm. Staff admitted to not communicating with each other correctly, which resulted in none of the staff
responding to R1's call pendant.

Per R1's care plan, he needs assistance with dressing, bathing, and toileting. R1 is a one-person assist.
R1 needs escort service to the toilet. R1 called for help to the restroom, and staff failed to help him in
a timely manner, causing R1 to sustain a fall and an injury. The allegation of Neglect/ Lack of Supervision is Substantiated.

On 10/10/2022, at 8:58pm, R1 pressed his call button to receive help to the restroom. Facility staff failed to
respond to R1's call for help in a timely manner, causing R1 to get up on their own. R1 got up, fell,
hitting his head on an unknown object. R1 laid on the ground for approximately 35 minutes before
staff checked on him. Once staff found R1, they immediately called 911 and AlphaOne was dispatched at
10:49pm

R1 was transported to hospital and diagnosed with a hip fracture. Staff openly admitted to failing to check on R1 in a timely manner, resulting in him falling, which caused him to break his right hip. R1 laid on the ground for approximately 35 minutes before staff provided aid. The allegation of Neglect/Lack of Supervision for failure to seek timely medical attention is substantiated as staff failed to provide aid, which resulted in R1 to lay on the ground for a prolonged amount of time.

based on the above information and statements obtained from staff members, the department has determined staff member did not respond to the call pendant for R1 as required. per records provided to the department, the facility staff did not respond to the call pendant pressed at 8:48pm until 10:22pm which resulted in the resident falling and sustaining an injury. The allegation of Neglect/ Lack of Supervision is Substantiated.

The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation of Neglect/Lack of Supervision is substantiated but if any additional information is received this complaint can be amended and the finding can be changed.

Report continued on LIC 9099-C, page 2 of 3.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 27-AS-20221104162120

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: 03/22/2023

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	Per California Code of Regulations, Title 22, the following deficiencies and immediate civil penalty have been issued. The circumstances of this complaint are being evaluated for enhanced civil penalties. Exit interview was conducted with the facility administrator. Appeal Rights were issued, and a copy of this report was left at the facility. . Page 3 of 3

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 27-AS-20221104162120

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/22/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/23/2023 Section Cited CCR 87465(a)(1)	1 2 3 4 5 6 7	Incidental Medical and Dental Care: The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by facility staff failed to check on call light after resident fell and sustained an injury resulting in a delay in treatment for	1 2 3 4 5 6 7	Facility has conducted staff training to address responding to call pendants and requests for assistance. facility staff have also conducted reviews of call logs to ensure facility staff respond in an appropraite amount of time. Facility will continue to conduct call log reviews and will report any instance where the call og was not responded to in under 35 minutes
	8 9 10 11 12 13 14	resident which poses an immediate health, safety and personal rights risk to residents in care.	8 9 10 11 12 13 14	to the deaprtment and identify the circumstances for the delay and identify any staff dicsipline if required.
Type A 03/23/2023 Section Cited CCR 87468.2(a)(8)	1 2 3 4 5 6 7	Additional Personal Rights of Residents in Privately Operated Facilities: To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement was not met as evidenced by staff failure to respond to call pendant when	1 2 3 4 5 6 7	Facility has conducted staff training to address responding to call pendants and requests for assistance. facility staff have also conducted reviews of call logs to ensure facility staff respond in an appropraite amount of time.
	8 9 10 11 12 13 14	resident needed assistance going to the bathroom wich resulted in resident falling and sustaing a hip fracture wich poses an immediate health safety and personal rights risk to resident in care.	8 9 10 11 12 13 14

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 4