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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347000985
Report Date: 05/08/2021
Date Signed: 05/08/2021 09:52:05 AM



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
06/19/2020 and conducted by Evaluator Michael Reber
COMPLAINT CONTROL NUMBER: 27-AS-20200619102551
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: 133DATE:
05/08/2021
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Jessica RiveraTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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 - Staff are not following resident's toileting needs
- Staff are not meeting resident's diabetic needs
- Staff are not responding timely to resident's alerts
- Staff are not following general sanitation practices
- Staff are not providing appropriate laundry services to residents
- Staff are not ensuring residents are properly fed while in care
INVESTIGATION FINDINGS:
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***************************************************DISCLAIMER**************************************************

Analyst Mike Reber originally delivered this report on 4/18/21, and had met with Kim Dickinson, to deliver investigation findings into the above stated allegations. Due to the Department experiencing technical difficulties, this information was lost during a migration of data to another computer server. An identical report from 4/18/21 is being delivered today in order to have the information stored in the Department's system. The hard copy of the report from 4/18/21 that was signed by Kim Dickinson will be stored in the facility file as well.

Analyst Mike Reber arrived at the facility today and met with Jessica Rivera to deliver investigation findings into the above stated allegations. During the course of the investigation, this analyst conducted interviews and obtained/reviewed documentation pertinent to the investigation.

Upon entering the facility, analyst spoke with staff to pre-screen that the facility was COVID free. Analyst also self-screened for having no known symptoms or exposure. Analyst followed facility's screening, wore an N-95 respirator and maintained distance during the visit.

******************************************Report continued on LIC 9099C*******************************************
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alycia BerrymanTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Michael ReberTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2021
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 3
Control Number 27-AS-20200619102551
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: 05/08/2021
NARRATIVE
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Allegation #1 - Staff are not following resident's toileting needs
According to the resident (R1) service plan obtained from the facility, R1 "requires physical assistance with parts of toileting tasks every 2(two) hours daily". Interviews with three staff and caregivers familiar with incontinence care duties for R1, state that staff check the resident every two hours and place their initials on the activities of daily living (ADL) log. By initialling the ADL log staff are stating that they conducted two hour rounds during their shift. Analyst reviewed a sample of three months of ADL logs for R1. The logs indicate that staff initial the log one time for each shift worked. The documentation does not indicate if the resident was incontinent during the shift or if staff changed or toileted the resident. Although staff are initialing the ADL log stating the resident was checked for incontinence every two hours, analyst is unable to determine if resident was toileted or if the resident was changed when discovered to be incontinent during a caregiver's shift .

Allegation #2 - Staff are not meeting resident's diabetic needs
The complaint report states that R1 is not getting insulin injections a half hour before his meals per doctor's order. A review of R1 physician's orders state that staff should check R1 blood sugar level four times daily (breakfast, lunch, dinner and bedtime) and inject insulin prior to each meal and bedtime nightly. A review of the medication administration record (MAR) for March, April, May and June 2020 indicates that resident receives injections four times daily (8am, 12pm, 5pm and 8pm). Interviews with four staff familiar with administering R1 insulin state that R1 always received his insulin before eating meals, and no staff interviewed were aware of any instances where R1 received an insulin injection after a meal was eaten. Although MAR records indicate R1 received his insulin at each meal and at bedtime, this analyst is unable to determine if the medication was administered before or after R1s meal was eaten.

Allegation #3 - Staff are not responding timely to resident alerts
Analyst obtained a copy of the Plan of Operation on Call Light System for the facility. The document states that staff "will strive to answer call lights within 12 minutes of activation". Staff will assess and prioritize each call for an emergency "in an attempt to safeguard resident emergencies and also ensure resident are being responded to in a timely manner." Analyst reviewed alarm event reports for five residents and in general, staff respond to call lights within the stated goal. Analyst did observe some calls to run past the 12 minute goal, interviews with caregivers and the director of care indicate that sometimes staff forget to reset the pendant after answering the call. Based on the evidence received, analyst is unable to determine if staff are not responding timely to resident alerts.
SUPERVISOR'S NAME: Alycia BerrymanTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Michael ReberTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20200619102551
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: 05/08/2021
NARRATIVE
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Allegation #4 - Staff are not following general sanitation practices
Reporting party (RP) states that staff are not washing R1 hands after toileting. RP also indicated during an interview on 3/9/21, that when staff change R1 the soiled disposable undergarment is placed in the trash can leaving the room malodorous. Interviews with four staff familiar with incontinence care all stated that when a resident is incontinent and changed, the soiled disposable undergarment is thrown in the trash but the trash is taken with them each time they leave the room and soiled undergarments are not left in a resident room. Staff also state that new gloves are used when entering a resident room and residents hands are washed. Analyst is unable to determine if this is done every time as stated by staff.

Allegation #5 - Staff are not providing appropriate laundry services to residents
The Golden Pond Assisted Living Residence and Care Agreement states "We will provide you with weekly Laundry service. If you request or require additional laundry service, such services will be provided for an extra fee". Interviews with two laundry staff indicates that laundry is done individual rooms at a time and no resident laundry is ever commingled. In an interview on 3/6/21 with the administrator of the facility stated that "upon admission, residents and their responsible party are advised to mark or label each article of clothing for identification and inventory their belongings, however, they cannot require someone to follow this request." A review of R1 Resident Personal Property and Valuables (LIC 621) indicates that R1 waived the option to inventory R1 belongings. Although items are alleged to be missing, analyst is unable to determine if the facility lost the items due to the lack of inventory of resident's belongings.

Allegation #6 - Staff are not ensuring residents are properly fed while in care
Analyst obtained dining room "meal tickets" that indicate requests are accommodated for R1 and R2. The tickets are completed by the resident and delivered to the resident room or served to the resident in the dining room. Interviews with wait staff and the director of care reveal that if an item is incorrect or missing from a residents food order, it is retrieved for the resident or if the item is unavailable a substitution is offered. Analyst is unable to determine if meals were missed or not served to resident.

Based on information obtained, Analyst finds the allegations to be UNSUBSTANTIATED - a finding meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

As a result of this investigation, no deficiencies were cited, per Title 22 Regulations, Division 6.

Exit interview conducted. Copy of report left with staff.

Signature obtained on hard copy of this report and placed in facility file.

SUPERVISOR'S NAME: Alycia BerrymanTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Michael ReberTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3