347000985-3-30-2023-27-AS-KHOS-CQUGRG-20230413053416

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347000985
Report Date: 03/30/2023
Date Signed: 03/30/2023 11:48:28 AM

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
03/27/2023 and conducted by Evaluator Kevin Gould

COMPLAINT CONTROL NUMBER: 27-AS-20230327163846

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: 103	DATE:	03/30/2023
		UNANNOUNCED	TIME BEGAN:	08:40 AM
MET WITH:	Tracy McLinn		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Personal Rights: Facility has cockroaches

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced complaint inspection at Golden Pond Retirement Community (RCFE) on 3/30/23 at 8:40am to inform the licensee of complaint allegation mentioned above.

During this investigation LPA Gould interviewed two staff members and three residents. LPA conducted a walkthrough of the facility and inspected two resident rooms and both food service and preparation areas in the facility. LPA observed no signs of insect infestation.

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: 03/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023

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-20230327163846

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: 03/30/2023

NARRATIVE

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Based on the interviews and statements obtained during the investigation process, the allegations cannot be substantiated because staff interviewed denied any insect infestation. The facility staff presented LPA with invoices for the last six months of preventative pest control. LPA conducted interviews with three residents. Two of the residents interviewed identified one incident where they observed 1 insect in their room. One resident reported observing one insect in their apartment several weeks ago with no further observation. This was not reported to staff. Another resident stated to have observed a beetle in their room on one occasion with no addition observations. LPA interviewed current resident council president who stated there have been no reported instances of insect infestation reported to them by other residents and feels the facility will be responsive should a resident identify an issue in their living unit.

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 Regulation, TITLE 22.

Exit interview was conducted with the facility administrator. 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: 03/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023

LIC9099 (FAS) - (06/04)

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