347000985-12-11-2023-27-AS-KGOD-CYELSG-20231211080040

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347000985
Report Date: 10/17/2023
Date Signed: 12/11/2023 08:00:44 AM

Document Has Been Signed on 12/11/2023 08:00 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	GOLDEN POND RETIREMENT COMMUNITY		FACILITY NUMBER:	347000985
ADMINISTRATOR:	AMANDA FRIEDMAN		FACILITY TYPE:	740
ADDRESS:	3415 MAYHEW ROAD		TELEPHONE:	(916) 369-8967
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95827
CAPACITY:	175	CENSUS: 95	DATE:	10/17/2023
TYPE OF VISIT:	Case Management - Legal/Non-compliance	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Amanda Friedman		TIME COMPLETED:	04:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 10/17/23 at 2:00pm, Department representatives Kevin Gould (LPA), Kim Viarella (LPA), Czarrina Camilon-Lee (LPM), Stephen Richardson (LPM) and Stephenie Doub (RM) met with representatives from Golden Pond Retirement Community to discuss recent compliance issues at the facility and the steps the facility is taking to address the department's concerns. Representing Golden Pond is Brian Walgenbach (Licensee), Amanda Friedman (Administrator) and Attorney Joel Goldman. The department addressed the concerns regarding the death of a resident and the facilities efforts to be in compliance with dementia care regulations. The facility has updated the facility smoking policy and evaluated all resident's with dementia to ensure no prohibited items are accessible to residents. Additional training and consultations with outside organizations. The department also addressed concerns regarding staff responses to signal system which resulted in resident injury. The facility has stated they have conducted training for staff in regards to responding to signal systems, auditing response times and continued consulting with outside organizations. The department and facility representatives discussed recent compliance issues with resident record keeping to ensure staff member shall have access to all up to date resident records to appropriately respond in case of emergency. Facility will continue ongoing training addressing resident documentation. facility continues to contract with a consulting group providing a nurse to audit med room systems. The department also discussed previous citations for annual assessments for dementia residents. Medication administration and following physician instructions. Elopement of Resident with dementia in memory care unit. The facility provided the department with updates and policies the facility has made to address the above issues including continued consultation with outside organizations and additional staff training. Report Continued on LIC 9009-C.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: GOLDEN POND RETIREMENT COMMUNITY	FACILITY NUMBER: 347000985
	VISIT DATE: 10/17/2023

NARRATIVE

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In summary the facility agreed to the following and will provide the department of documentation of policy and procedure changes.

Facility will identify residents with Dementia and ensure prohibited items described in regulations are made inaccessible and the procedure in which to store these items. Included in the POC is the current Resident Smoking Policy, The Policy/Procedures regarding smoking and the documented staff training.
Staff training and knowledge of centrally stored resident records to ensure all staff members have access to updated resident documents.
Continue ongoing training addressing resident documentation. facility continues to contract with a consulting group providing a nurse to audit med room systems.
Call light response is monitored and reviewed by the Director of Care and appropriate action is taken if staff do not respond in an appropriate amount of time.
Elopement risk is evaluated with our residents. Residents are monitored and checked if not in the line of vision of the staff. Facility will continue to evaluate suitable outdoor furniture for memory care space to meet the needs or residents.

Per California Code of Regulations, Title 22 there were no deficiencies cited during today's meeting. An exit interview was conducted, and a copy of this report was mailed to the facility for signature.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023

LIC809 (FAS) - (06/04)

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