347000985-5-21-2021-27-AS-KMKY-C47PEK-20210621111516

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347000985
Report Date: 05/21/2021
Date Signed: 05/21/2021 11:25:41 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/21/2020 and conducted by Evaluator Pheej Cheng

COMPLAINT CONTROL NUMBER: 27-AS-20200921120045

FACILITY NAME:	GOLDEN POND RETIREMENT COMMUNITY		FACILITY NUMBER:	347000985
ADMINISTRATOR:	STEPHEN SARINE		FACILITY TYPE:	740
ADDRESS:	3415 MAYHEW ROAD		TELEPHONE:	(916) 369-8967
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95827
CAPACITY:	175	CENSUS: 93	DATE:	05/21/2021
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Guadelupe Ramirez; Administrator		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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1) Resident sustained stage 2 pressure injuries while in care.
2) Staff do not properly maintain the facility.
3) Licensee did not adequately staff facility to meet residents’ needs.

INVESTIGATION FINDINGS:

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On 5/21/21 at 9:15 AM, Licensing Program Analyst (LPA) Cheng conducted an unannounced complaint investigation visit to deliver the findings of the above allegation and met with Administrator Guadelupe Ramirez. Prior to initiating the complaint visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted Administrator and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Masks and gloves. Additionally, LPA was screened by Administrator Guadelupe Ramirez.

Continuation on LIC 9099C.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Rayna L Bryson	TELEPHONE: (530) 895-5991
LICENSING EVALUATOR NAME: Pheej Cheng	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2021

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-20200921120045

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: GOLDEN POND RETIREMENT COMMUNITY	FACILITY NUMBER: 347000985
	VISIT DATE: 05/21/2021

NARRATIVE

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1) Resident sustained stage 2 pressure injuries while in care.
Based on statements, physician’s report, hospice notes obtained and LPA’s observation on 9/29/2020, LPA determined that the allegation is false. R1 is not diagnosed with any stages of pressure injuries. R1’s physician’s report and Hospice care plan does not indicate that R1 has any stages of a pressure injury; however, the hospice notes obtained do indicate that R1 has a rash that is currently being treated with medication. R1's hospice notes did not diagnose the rash as a pressure injury. Staff statements confirms that R1 does have a rash and it is being treated with a cream. During LPA’s virtual visit on 9/29/2020, LPA did not observe any pressure injuries. LPA did observe a rash that was located on the resident’s lower right back.

2) Staff do not properly maintain the facility.
Based on statements obtained and observations on 9/29/2020, LPA determined that the allegation is not true. All staff interviewed stated that housekeeping is completed at least five days a week and that laundry is completed every day. All staff members interviewed stated that the Memory Care Unit (MCU) does not smell of any odor. When housekeeping is not working, Caregivers are assisting in cleaning the MCU and laundry. Staff statements show that there's no knowledge of resident shower curtains having feces on them. During LPA’s virtual visit on 9/29/2020, LPA observed that all rooms appeared to be clean and fully furnished. LPA did not observe any resident' shower curtains to have feces on them. LPA observed that facility has a 7-day non-perishable and 2-day perishable supply of food.

Continuation on LIC 9099C.

SUPERVISOR'S NAME: Rayna L Bryson	TELEPHONE: (530) 895-5991
LICENSING EVALUATOR NAME: Pheej Cheng	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2021

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20200921120045

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: GOLDEN POND RETIREMENT COMMUNITY	FACILITY NUMBER: 347000985
	VISIT DATE: 05/21/2021

NARRATIVE

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3) Licensee did not adequately staff facility to meet residents’ needs.
Based on statements, facility documents obtained, and e-mail correspondence, LPA determined that the above allegation did not occur. All staff interviewed stated that the MCU is sufficiently staffed; some staff members even stated that they were over staffed. Residents are checked on at least every two hours or more if needed. Each bi-hourly check includes a resident diaper change if needed. R2’s physician’s report indicates that R2 is prone to skin tears; which correlates with statements obtained stating that R2 has scabs along her legs due to R2 picking at it. All staff statements indicate that water is available for all residents. Staff members interviewed indicated that there is no knowledge of residents being left in soiled diapers or diapers filled with feces. Facility’s contracted podiatrist confirmed that monthly nail clipping services were provided monthly in 2020 with an exception between 9/2020 to 12/2020; nail clipping services were conducted by S15 and only consisted of nail filing and not actual nail clipping.

This agency has investigated the complaint allegations listed above. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without reasonable basis. We have therefore dismissed the complaint.

Exit interview conducted and a copy of report was provided.

SUPERVISOR'S NAME: Rayna L Bryson	TELEPHONE: (530) 895-5991
LICENSING EVALUATOR NAME: Pheej Cheng	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2021

LIC9099 (FAS) - (06/04)

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