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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347000985
Report Date: 11/08/2023
Date Signed: 11/08/2023 12:30:23 PM


Document Has Been Signed on 11/08/2023 12:30 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:
11/08/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Amanda FriedmanTIME COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kevin Gould made an unannounced Case Management Deficiencies inspection to Golden Pond Retirement Community (RCFE) on 11/8/23 at 9:00am to address deficiencies observed during a complaint inspection. LPA Gould met with Administrator Amanda Friedman and together discussed LPA's findings.

LPA Gould conducted staff interview regarding resident items that were lost, misplaced or stolen while at the facility. LPA's interviews confirmed that within the last two years of facility operation there have been items go missing (no allegations of theft by facility staff) and were not able to be found or recovered by staff members. LPA Gould reviewed the facility theft loss policy binder and observed no new documentation of items missing since 2014. Based on the interviews and statements obtained and the lack of documentation in the theft loss policy binder; the department has concluded the facility has not followed their own plan of operation and documented theft loss policy per Title 22 regulations.

The following deficiencies are 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-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/08/2023 12:30 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: 11/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/06/2023
Section Cited
CCR
87218(a)

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The licensee shall ensure an adequate theft and loss program as specified in Health and Safety Code Section 1569.153. This requirement was not met as evidenced by staff statements obtained during the inspection and review of the facility theft/loss prevention binder which lacked
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facility will submit update written policies and procedure to ensure theft loss policy meets regulations and provide documentation of all staff training on the subject by the POC due date.
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documentation of any theft/loss since 2014 and staff interviews indicated more recent items going missing or lost which poses a potential health safety and personal rights risk to residents in placement.
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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: 11/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2023
LIC809 (FAS) - (06/04)
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