347000985-6-29-2023-27-AS-KHOS-CUB2PB-20230801173400

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347000985
Report Date: 06/29/2023
Date Signed: 06/29/2023 03:58:48 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 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: 99	DATE:	06/29/2023
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Amanda Friedman		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Questional 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. LPA met with facility staff and together discussed the investigation details. 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.

Based on the interviews and documentation obtained during the investigation process, the allegations are substantiated. The department has determined, the deceased resident did have diagnosis of dementia per her Physician's Report dated 4/26/21. Per title 22 regulations, for resident's with a diagnosis of dementia, items such as matches or cigarettes shale be stored inaccessible to residents in care. Per previous interviews conducted by the department, the former residents cigarettes were not stored inaccessible to the resident which resulted in the reported incident on 12/27/22 and the resident's subsequent death as a result of the injuries sustained. Report Continued on LIC 9099-C

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: 06/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023

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-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: 06/29/2023

NARRATIVE

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The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation of Questionable Death is substantiated.

The following deficiency is cited per California Code of Regulations, TITLE 22. The circumstances of this complaint are being evaluated for enhanced civil penalties by the department.

Exit interview was conducted with the facility staff member. 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: 06/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023

LIC9099 (FAS) - (06/04)

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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: 06/29/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/30/2023 Section Cited CCR 87705(f)(2)	1 2 3 4 5 6 7	Care of Persons with Dementia: The following shall be stored inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.	1 2 3 4 5 6 7	in collaberation with LPA and the facility staff, the facility will identify all residents with dementia and ensure prohibited items described in regulations are made inacessible. The facility will provide a written plan on how prhibited items can be stored and made safely accessible to residents in care
	8 9 10 11 12 13 14	This requirement was not met as evidence by: former resident was diagnosed with dementia and had access ot her cigarettes in violation of regulations which resulted in injuries and the death of the resident wich poses an immediate health safety and personal rights risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 06/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023

LIC9099 (FAS) - (06/04)

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