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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347000985
Report Date: 03/30/2023
Date Signed: 06/29/2023 03:56:56 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
12/29/2022 and conducted by Evaluator Kevin Gould
COMPLAINT CONTROL NUMBER: 27-AS-20221229095800
FACILITY NAME:GOLDEN POND RETIREMENT COMMUNITYFACILITY NUMBER:
347000985
ADMINISTRATOR:TRACY MCLINNFACILITY TYPE:
740
ADDRESS:3415 MAYHEW ROADTELEPHONE:
(916) 369-8967
CITY:SACRAMENTOSTATE: CAZIP CODE:
95827
CAPACITY:175CENSUS: 103DATE:
03/30/2023
UNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Amanda FriedmanTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Questionable death:
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kevin Gould made an unannounced inspection to Golden Pond Retirement Community (RCFE) on 6/29/23 at 1:45pm to amend the report for the investigation of the above allegation and to deliver the findings. This report is being amended due to an error discovered in the investigation conducted by the department which resulted in a erroneous determination of the findings. A new report will be generated that supersedes this report.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (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)
Page: 1 of 6
Control Number 27-AS-20221229095800
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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This report is being amended due to an error discovered in the investigation conducted by the department which resulted in a erroneous determination of the findings. A new report will be generated that supersedes this report.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (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)
Page: 2 of 6
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
12/29/2022 and conducted by Evaluator Kevin Gould
COMPLAINT CONTROL NUMBER: 27-AS-20221229095800

FACILITY NAME:GOLDEN POND RETIREMENT COMMUNITYFACILITY NUMBER:
347000985
ADMINISTRATOR:TRACY MCLINNFACILITY TYPE:
740
ADDRESS:3415 MAYHEW ROADTELEPHONE:
(916) 369-8967
CITY:SACRAMENTOSTATE: CAZIP CODE:
95827
CAPACITY:175CENSUS: 103DATE:
03/30/2023
UNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Tracy MclinnTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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1) Administrator qualifications:
administrator allowed resident to moke in non-designated area in violation of fire clearance.
2) Fire clearance:
Facility did not follow fire clearance and allowed resident to smoke in non-designated area in the facility.
3) Personal rights:
Resident smoking in non-desigated area resulted in fire and danger to other residents in care.
INVESTIGATION FINDINGS:
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On 3/30/23 Licensing Program Analyst (LPA) Kevin Gould made an unannounced inspection to the Golden Pond Retirement Community 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 because it was determine by the department that the facility operated in violation of the fire clearance by allowing a resident to smoke on their balcony which is not the designated smoking area identified the facility fire clearance. As all residential care facilities are non-smoking the department has determined the allegation of Fire Clearance is substantiated.

Additionally, the department has determined that by allowing the resident to smoke on the balcony and not the designated smoking area, and subsequent fire that developed as a result of this violation, the personal rights of all residents in placement at the facility were violated as the fire posed a potential health and safety risk to residents in care. The department has determined the allegation of Personal Rights is substantiated.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (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)
Page: 3 of 6
Control Number 27-AS-20221229095800
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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The department has also determined that, although facility agreement for resident to smoke on their balcony and admission of the resident pre-dated the current administrator, once it was identified that the resident's smoking violated the facility fire clearance; the facility administrator should have terminated the agreement and enforced the fire clearance. The resident should not have been allowed to continue to smoke on their balcony as it violated the fire clearance and posed a potential health, safety and personal rights risk to residents in care.

The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation of Fire clearance, Personal Rights and Administrator Qualifications is substantiated but if any additional information is received this complaint can be amended and the finding can be changed.

The following deficiencies are cited per California Code Regulation, TITLE 22. the circumstances of this case is being evaluated for an enhanced civil penalty.

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-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (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)
Page: 4 of 6
Citations on this Visit Report are Under Appeal!

Control Number 27-AS-20221229095800
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: 03/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
03/31/2023
Section Cited
CCR
87203
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Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement was not met as evidenced by facility knowingly violated fire clearance by allowing resident to smoke on their
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facility will submit a written plan of correction identifying all the designated locations a resident will be able to smoke outside the facility and will submit a updated facility sketch that identifies the designated smoking locations so the department may ensure the facility is following all fire clearances as determined by the fire marshal.
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balcony and not in a designated location which resulted in a fire at the facility poses an immediate health, safety and personal rights risk to residents in care.
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Under Appeal
Type A
03/31/2023
Section Cited
CCR
87468.1(a)(2)
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Personal Rights of Residents in All Facilities: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by the facility allowing a resident to smoke on their balcony and subsequently starting a fire in their unit posed a personal rights risk to
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Facility has agreed to submit a written plan of correction by the POC due date that shows facility staff have reviewed fire clearance regulations and the facility understand the risks associated with a violation of fire clearance to residents in care.
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resident safety which posed an immediate health, safety and personal rights risk to residents in care.
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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-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Citations on this Visit Report are Under Appeal!

Control Number 27-AS-20221229095800
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: 03/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type B
04/07/2023
Section Cited
CCR
87405(d)(2)
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Administrator - Qualifications and Duties: Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement was not met as evidenced by facility administrator knowingly allowed a resident to smoke in a non-designated area in the facility in violation of the facility fire clearance which did result in a fire in a
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Administrator will provide a written plan or reviewing physician reports and developing a plan for smoking in designated areas. Facility administrator will also provide a written plan for those residents who may not be safe wile smoking in a designated area and developing a plan for staff supervision for those residents.
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residnet's unit which poses a potential health, safety and persoanl rights risk to residents in care.
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for existing residents we the facility will identify current smokers and will re-evaluate to ensure they can smoke as their preferred activity. The facility has already identified a resident who requires staff supervision in designated areas.
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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-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6