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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347000985
Report Date: 05/01/2025
Date Signed: 05/01/2025 03:44:05 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/15/2024 and conducted by Evaluator Kimberly Viarella
COMPLAINT CONTROL NUMBER: 27-AS-20240815141325
FACILITY NAME:GOLDEN POND RETIREMENT COMMUNITYFACILITY NUMBER:
347000985
ADMINISTRATOR:RYAN NAKAOFACILITY TYPE:
740
ADDRESS:3415 MAYHEW ROADTELEPHONE:
(916) 369-8967
CITY:SACRAMENTOSTATE: CAZIP CODE:
95827
CAPACITY:175CENSUS: 94DATE:
05/01/2025
UNANNOUNCEDTIME BEGAN:
08:47 AM
MET WITH:Ryan Nakao TIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Facility staff are not conducting proper assessments.
INVESTIGATION FINDINGS:
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On 05/01/25, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to deliver the findings of this complaint investigation. LPA identified herself upon arrival, state the purpose of the visit and asked to meet with the Designated Facility Administrator/Executive Director (ED). LPA met with Ryan Nakao and a brief interview followed.

Regarding the allegation: Facility staff are not conducting proper assessments.

During this investigation, this LPA requested a sample of resident files including their pre-appraisals, any re-appraisals and care plans. This LPA learned that there was an assessment tool (Yardi) that was supposed to be utilized to determine each resident's care plan, including fall risk. This LPA also learned during interviews and a review of records that this tool was not consistently or properly used by S7. Upon reviewing the file for resident 5 (R5), LPA observed that the resident's pre-appraisal (dated 3/29/22) was completed after the admissions agreement was signed (3/28/22) and the file did not contain
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025
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-20240815141325
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: GOLDEN POND RETIREMENT COMMUNITY
FACILITY NUMBER: 347000985
VISIT DATE: 05/01/2025
NARRATIVE
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an assessment.

Upon reviewing the file for R4, LPA found that it contained a "Health and Service Evaluation" which contained a date in the lower corner, "Monday, May 15, 2023", the document was not on letterhead of any kind and did not contain any names, signatures or dates to indicate where the document came from or who conducted the evaluation. It was noted that it was a return re-assessment, but there were no other comments included as to why the resident was being re-assessed. Handwritten notes contradict the assessment in places: on page 3 the assessor indicated that R4 "requires a 2-person total assistance and/or is incontinent." To the side, a handwritten note was added that stated, "1 person w/t pole." (A T-pole is a floor to ceiling transfer pole or security pole designed to provide additional stability for residents with mobility issues.) LPA observed that there was check mark that R4 was a fall risk, however, no additional status checks were indicated under the section titled, "Additional Status Checks." Under the section pertaining to how many times a day the resident would receive medications, a handwritten note was added, "not sure." On page 4 fall concern was listed as "0" however, on page 6 handwritten notes included "Order" next to gait belt, and next to walker, the notes added were "large walker/order." The last two Physician's Reports (LIC 602s) for this resident dated 4/17/24 and 9/3/24 both stated that R4 was nonambulatory, had mild cognitive impairment, and had a history of seizure disorders. The pre-appraisal for R4 was dated 4/16/24 and the admissions agreement was signed on 4/14/24. Again, one of the tools used to determine if the facility can meet the needs of the resident prior to admissions, was used after the resident had already entered into the contract. LPA requested all appraisals and service plans. The only service plans provided to this LPA were assessed by and modified by S7 on 12/10/24. The plan included signature lines for the resident, the responsible party, and the resident care director. All were blank.

LPA reviewed the Physician's Report for R6 dated 9/10/24 which stated that the resident had a diagnosis of Alzheimer's, heart block, urinary retention, Congestive Heart Failure (CHF )and dementia. It stated that R6 required a cardiac diet, had a bladder impairment, auditory and visual impairments, wandering behavior, that R6 was confused and disoriented, able to communicate needs, and able to leave the facility unassisted. It also stated that R6 was unable to bathe and dress themselves, manage their own cash resources and "might require help" with toileting needs. The report also stated that R6 could not independently transfer to and from bed. The physician made a mark under ambulatory and above nonambulatory with a note stating they R6 would need help leaving the facility if there were a fire. The physician described R6's medical condition as
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 27-AS-20240815141325
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: GOLDEN POND RETIREMENT COMMUNITY
FACILITY NUMBER: 347000985
VISIT DATE: 05/01/2025
NARRATIVE
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"Fair". There were sections in the report that the facility should have gotten clarification on, particularly the fact that the resident with Alzheimer's and dementia was "able to leave the facility unassisted" as well as the resident's ambulatory status. LPA requested updated information regarding this resident and the concerns listed above and the facility was unable to provide any at the time of the inspection.

LPA reviewed the care plan for R6 dated 10/15/24. Under "Meal Consumption or Special Care," the required cardiac diet, which was listed on the LIC 602 dated 9/10/24, was not listed as part of R6’s care plan. Again, this care plan included signature lines for the resident, the responsible party, and the resident care director. All were blank.

LPA reviewed R5's file and found fax cover sheets to R5's doctor informing the doctor that R5 had fallen. There were 13 separate incidents from 08/01/24 - 01/21/25. LPA reviewed 8 service plans for R5 looking for changes in condition and updates over time. The last 4 were dated 02/08/24, 06/25/24, 01/09/25 and 02/21/25. In every one of these service plans, R5 was listed as a low fall risk. No additional strategies or services were listed to prevent R5 from falling. No additional scheduled checks were included in R5's service plan.

The standard for the preponderance of evidence has been met. The allegation: Facility staff are not conducting proper assessments has been SUBSTANTIATED and will be cited on the LIC 9099D page.

According to the California Code of Regulations Title 22, no other deficiencies were observed or cited during today's visit. A copy of this report and APPEAL RIGHTS were provided. Exit interview.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 27-AS-20240815141325
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GOLDEN POND RETIREMENT COMMUNITY
FACILITY NUMBER: 347000985
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/01/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/30/2025
Section Cited
CCR
87459(a)
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87459 (a) The facility shall assess the person's need for personal assistance and care by determining his/her ability to perform specified activities of daily living...
Such activities shall include, but not be limited to:

(1) Bathing, including need for assistance:




(D) Walking with or without equipment or other assistance.

(E) Dietary limitations.

(F) Medical history and problems.

(G) Need for prescribed medications.






The facility did not ensure the above regulation was met as evidenced by:
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The Administrator stated that the Memory Care Coordinator and the Care Coordinator completed Yardi training to improve their understanding of how to utilize and implement this tool properly. This was completed April 2025. The facility also stated that they will audit their resident files to ensure that their
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Based on a review of records, in 3 cases, evaluation/appraisals for 3 residents were not incomplte, contained contradictory information, or not completed in a timely manner. This posed/poses a potential threat to the health, safety and/or personal rights of residents in care.
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accurate and current and that they identity how to meet the needs of their residents.
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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.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/15/2024 and conducted by Evaluator Kimberly Viarella
COMPLAINT CONTROL NUMBER: 27-AS-20240815141325

FACILITY NAME:GOLDEN POND RETIREMENT COMMUNITYFACILITY NUMBER:
347000985
ADMINISTRATOR:RYAN NAKAOFACILITY TYPE:
740
ADDRESS:3415 MAYHEW ROADTELEPHONE:
(916) 369-8967
CITY:SACRAMENTOSTATE: CAZIP CODE:
95827
CAPACITY:175CENSUS: 94DATE:
05/01/2025
UNANNOUNCEDTIME BEGAN:
08:47 AM
MET WITH:Ryan Nakao TIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Facility does not have sufficient staff to meet residents needs.
INVESTIGATION FINDINGS:
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On 05/01/25, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to deliver the findings of this complaint investigation. LPA identified herself upon arrival, state the purpose of the visit and asked to meet with the Designated Facility Administrator/Executive Director (ED). LPA met with Ryan Nakao and a brief interview followed.

Regarding the allegation: Facility does not have sufficient staff to meet residents needs

Based on interviews and a review of staff schedules provided at the time this complaint was initiated, (08/15/24), this LPA learned that the Care Coordinator scheduled 4 care staff for the AM shift, (6:00 AM - 2:30 PM) 4 for the PM shift (2:00 PM - 10:30 PM) and 2 care staff for the nocturnal "NOC" shift (10:00 PM - 6:30 AM). The Health and Wellness Director scheduled 3 medication technicians during the AM shift, 2 for the PM, and 1 for the NOC. LPA reviewed 3 months of schedules and they reflected that staff were being scheduled according to what these two department heads stated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 27-AS-20240815141325
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: GOLDEN POND RETIREMENT COMMUNITY
FACILITY NUMBER: 347000985
VISIT DATE: 05/01/2025
NARRATIVE
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When interviewed, both staff and residents had mixed responses when asked if there was enough staff to meet the needs of the residents. This LPA learned that there had been call outs but both the Care Coordinator and the Health and Wellness Director stated that they were hands-on and assisted on the floor with residents when needed in order to make up for someone calling out.

Interviewees could not provide dates and times of when staffing was insufficient with examples of what needs were not being met during and around the month of August. The standard for meeting the preponderance of evidence was not met and the Department found this allegation UNSUBSTANTIATED.

A finding of unsubstantiated means that the allegation MAY have happened or IS valid, but there is not a preponderance of evidence that the alleged violation occurred.

According to the California Code of Regulations, no deficiencies were observed or cited during today's visit.
A copy of this report was provided, along with APPEAL Rights. Exit interview.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6