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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347000985
Report Date: 07/15/2025
Date Signed: 07/29/2025 03:15:04 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
01/22/2025 and conducted by Evaluator Kimberly Viarella
COMPLAINT CONTROL NUMBER: 27-AS-20250122143006
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:
07/15/2025
UNANNOUNCEDTIME BEGAN:
08:10 AM
MET WITH:Ryan NakaoTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff are not being properly trained.
INVESTIGATION FINDINGS:
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This report was amended to reflect that it was delivered on 07/15/25 when Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to deliver the findings of this complaint investigation into the above allegation. LPA identified herself upon arrival, stated 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: Staff are not being properly trained.

LPA reviewed the personnel files to ensure that the initial and annual trainings were up to date for all the medication technicians at the time of this complaint. LPA found that in 4 out of 4 staff files reviewed, (S2, S6, S5, and S19) none of the staff had the required documentation to ensure that all of the training required under the California Code of Regulations, Title 22 had been completed. Under Health and Safety Code 1569.69(a)(1), "In facilities licensed to provide care for 16 or more persons, the employees shall complete 24 hours of initial training. This training shall consist of 16 hours of hands-on shadowing, which shall be
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2025
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 8
Control Number 27-AS-20250122143006
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: 07/15/2025
NARRATIVE
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completed prior to assisting with the self-administration of medications, and 8 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first 4 weeks of employment."
4 out of the 4 files reviewed did not have documentation to demonstrate that 16 hours of required shadowing had been completed. Through interviews with the Executive Director, this LPA learned that Medication Technicians at this community also provide direct care when needed. For instance, if care staff need assistance with a 2-person lift, and no one else is available, a medication technician was called. They also respond to resident call alerts when instructed to do so.

S2 utilized computer software training to complete 4 hours of the required 8 hours of training on the specific topics listed in the Health and Safety Code section 1569.69(a)(4) during their second month of employment. There was a 1 page signature sheet with the heading for Diabetic Monitor Training dated 02/12/25, 7 names were listed but S2's was not. An additional line was added at the bottom with the date 04/24/25 with S2's signature. This occurred beyond the 1-month deadline and there was no agenda included, trainer credential information, or length of duration for the training. There were 2 other handouts with S2's signature in the file, along with an agenda for a staff meeting on 04/29/25, however, the one-page handouts were not on topics that were required as part of the 8 hours of training. A Certificate of Achievement for completing their Medication Technician training was dated 4/01/25, although S2 was hired on 01/22/25. This exceeded the required time frame to complete training by over 2 months.

S6 was hired as a Medication Technician on 1/13/23. LPA observed a signed document with S6's name and the initials of the Wellness Director documenting 24 hours of training. The document was dated 03/06/23. Training was not completed within the required time frame. LPA also observed that for 2024, 5.25 hours of online training was completed, none specifically on medication, and therefore did not meet the 8-hour annual refresher training requirement. Records showed that S6 did not begin their medication technician training until 7 months later. They then completed 7 hours of online training specific to becoming a medication technician. This was in violation of the regulations as it was not completed within the required time frame. S6 did not have the required training for a Medication Technician or for staff who assist residents with personal activities of daily living as per California Code of Regulation 87411.

LPA was provided a hire date of 08/12/24 for S19. LPA observed that their computer based training totaled 28.75 hours from 08/09/24- 09/18/24. S19 Completed 8 hours of online dementia care training, but not the
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 27-AS-20250122143006
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: 07/15/2025
NARRATIVE
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required 12 during the time frame above. No certificate of completion was included in their file. S19 did not pass the test the first time and at the top was the note "Med Tech was able to answer all questions correct after verbal review on 8/13/24" the day after the exam was administered. A re-test for competency was not conducted. No additional annual computer based training was documented for 2025. Inside S19's file, LPA observed a cover sheet that listed 23 training items, 3 were crossed off and labeled "N/A." There were 11 competency checklists included in the file. 8 of them were signed and dated by their trainer. They did not include the time taken for the training or required 16 hours of shadowing experience and all were dated 8/15/24. The credentials of the trainer were also not included. S19 did not have the required training for a Medication Technician or for staff who assist residents with personal activities of daily living as per California Code of Regulation 87411.

S5's date of hire was 10/11/22. S5 moved from working in the kitchen to a position as a Medication Technician on 02/24/25. S5 completed 32.75 hours of Relias training completed from 09/26/23 to 03/17/25. Five hours were specifically related to their position in food service and prior to direct care and medication technician duties, therefore their applicable Relias training totaled 27.75 hours. S5's first 6 hours of dementia care training were not completed prior to providing care. 12 hours were not completed in the first 4 weeks of employment. 40 hours of training were not completed in the first 4 weeks. S5's certificate of completion for med tech training was dated 1/22/25, but the date on the competency exam was 2/5/25. There were handouts regarding hospice, procedures for when a resident has a fall, agendas for staff meetings, ordering medications and more. If they were a part of a training, the date, time/length of training, and facilitator, along with their credentials, were not included. S5 did not have the required training for a Medication Technician or for staff who assist residents with personal activities of daily living as per California Code of Regulation 87411.

None of the 4 files reviewed contained First Aid and/or CPR certifications. Health and Safety Code section 1569.618 states that,"(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR." Further, CCR 87411 states that, "(C) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross."
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 27-AS-20250122143006
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: 07/15/2025
NARRATIVE
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 Through interviews with S1, S8, and S9, this LPA learned that neither the medication technician staff nor other direct care staff received First Aid or CPR training through a qualified agency.

The standard for the preponderance of evidence has been met and the allegation, " Staff are not being properly trained," has been SUBSTANTIATED. This Deficiency has been cited on the LIC 9099 D page.

According to the California Code of Regulations, Title 22 no other deficiencies were cited during today's visit, a copy of this report was provided along with APPEAL RIGHTS and an exit interview conducted.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 8
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
01/22/2025 and conducted by Evaluator Kimberly Viarella
COMPLAINT CONTROL NUMBER: 27-AS-20250122143006

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: DATE:
07/15/2025
UNANNOUNCEDTIME BEGAN:
08:10 AM
MET WITH:Ryan NakaoTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff mishandle the residents medications.
INVESTIGATION FINDINGS:
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On 07/08/25, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to deliver the findings of this complaint investigation into the above allegation. LPA identified herself upon arrival, stated 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: Staff mishandle the residents' medications.

Based on interviews with S1, S4, S7, S9, and S19, there have been multiple medication errors.  During a review of the personnel files for the medication technicians, this LPA observed the following documentation.  In S19's file, that was a document from the Wellness Director dated 11/06/24 regarding "several medications that were not charted." On 01/17/25, there was a document from the Wellness Director stating that “the incorrect medications" were poured for a resident in assisted living.  S19 gave the medications for the resident (R2) to resident (R3). 

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2025
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 8
Control Number 27-AS-20250122143006
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: 07/15/2025
NARRATIVE
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In interviews with S19, S4, and S9, there was another instance in the memory care community where S19 gave medications to the wrong resident. This was not documented in S19's file.  According to interviews with S4 and S7 loose pills have been found in the memory care community.  The standard for the preponderance of evidence has been met and the allegation, "Staff mishandle the residents’ medications," has been SUBSTANTIATED. This deficiency has been cited on the LIC 9099 D page.

According to the California Code of Regulations, Title 22 no other deficiencies were cited during today's visit, a copy of this report was provided along with APPEAL RIGHTS and an exit interview conducted.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 27-AS-20250122143006
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: 07/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/16/2025
Section Cited
CCR
87465(a)(4)
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(4) The licensee shall assist residents with self administered medications as needed." This requirement was not met as evidenced by:
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The Executive Director(ED) stated that the employee who made the errors was terminated. The ED stated that they have just hired a new Wellness Director and together they will be utilizing the training log provided by the technical support program to ensure that all required is
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Based on interviews and a review of records, S19 gave the wrong medication to two different residents on 2 different occasions. This posed/poses an immediate threat to the health safety and /or personal rights of the residents in care.
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The ED stated he will submit and outline the hours allocated for each training topic to this LPA by the close of business on 07/16/25 and submitted to kimberly.viarella@dss.ca.gov
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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: 07/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 27-AS-20250122143006
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: 07/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/01/2025
Section Cited
HSC
1569.69(a)
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Employees assisting with sellf-admini-
stration of medication; training require- ments (a)...shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements... This requirement was not met as evidenced by:
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The ED stated that they have just hired a new Wellness Director and togehter they will be utilizing the training log provided by the technical support program to ensure that all required is completed and by the close of business by 09/01/25 and submitted to Community Care Licensing
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In 4/4 files reviewed, this LPA observed that training did not meet the requirements mandated. This poses/posed a potential risk to the health, safety and personal rights of the residents in care.
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 at CCLASCPSacramentoRO@dss.ca.gov
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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: 07/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2025
LIC9099 (FAS) - (06/04)
Page: 8 of 8