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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347000985
Report Date: 10/03/2023
Date Signed: 10/03/2023 03:33:50 PM


Document Has Been Signed on 10/03/2023 03:33 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 COMMUNITYFACILITY NUMBER:
347000985
ADMINISTRATOR:AMANDA FRIEDMANFACILITY TYPE:
740
ADDRESS:3415 MAYHEW ROADTELEPHONE:
(916) 369-8967
CITY:SACRAMENTOSTATE: CAZIP CODE:
95827
CAPACITY:175CENSUS: 99DATE:
10/03/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Amanda FriedmanTIME COMPLETED:
03:45 PM
NARRATIVE
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On 10/3/23 at 1:45pm, Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced Case Management Deficiencies inspection to address deficiencies observed by the department related to in the reported incident dated 12/26/22.

The department has determined based on a review of evidence collected that the facility did not meet all requirements of Title 22 regulations that were not identified when previously investigated by the department.
The department has determined, the facility not adhere to all aspects of dementia care regulations under tittle 22 by allowing a resident with dementia access to cigarettes and matches/lighter which is prohibited under 87705 (care for persons with dementia) sections, f (1) and (2). By allowing the resident with dementia access to cigarettes and lighter/matches, the administrator at the time of the reported incident, did not display knowledge of requirements for the care and supervision on R1 who passed away as a result of injuries sustained while partaking in their preferred activity of smoking.

The department has also determined the facility did not meet the basic services for R1 as identified in the Health and safety code in terms of ensuring the general health, safety and well-being for R1 as staff members did not meet regulations for supervision of resident while the resident partook in their preferred activity of smoking which resulted in R1's death from injuries sustained while smoking.

Per California Code of Regulations, Title 22 the following deficiencies are cited during today's inspection. An exit interview was conducted, and a copy of this report and appeal rights were 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: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 10/03/2023 03:33 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/04/2023
Section Cited
CCR
87405(d)(1)

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Administrator Qualifications and Duties: Knowledge of the requirements for providing care and supervision appropriate to the residents. This requirement was not met as evidenced by the facility administrator failed to demonstrate adequate
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Facility will submit updated written smoking policy that addresses smoking for residents diagnosed with dementia.
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knowledge of regulatory requirements and to ensure safeguarding dementia resident R1 from having access or possession of cigarettes and proper oversight of supervision for R1s smoking.
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Type A
10/04/2023
Section Cited
HSC1569.312(e)

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Basic Services Requirements: Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety, and well-being. This requirement was not met as evidenced by Facility staff failed to
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Facility will provide in service training to all staff members and provide documentation of training to supervise resident's with a diagnosis of dementia while smoking.
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adequately supervise and monitor R1’s activity on 12/26/22.
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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: 10/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2