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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347000985
Report Date: 07/29/2025
Date Signed: 07/29/2025 11:55:13 AM

Unsubstantiated


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
01/30/2025 and conducted by Evaluator Kimberly Viarella
COMPLAINT CONTROL NUMBER: 27-AS-20250130163859
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: 96DATE:
07/29/2025
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Ryan NakaoTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Facility staff acting unprofessionally in front of residents.
INVESTIGATION FINDINGS:
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On 07/29/25, Licensinng Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to deliver the findings for the investigation into the above allegation. LPA idenitified herself upon arrival, stated the purpose of the visit, and asked ot meet with the Designated Faciltiy Administrator/Executive Director (ED), Ryan Nakao. The two met and a brief interview followed.

Regarding the allegation: "Facility staff acting unprofessionally in front of residents."

There was an incident that took place on or about the first week of June in 2024, when a caregiver experienced a medical issue and was found unconscious and unresponsive on the floor. Staff on duty began calling the Director of Care (DC) whose shift had ended and was gone for the day. According to interviews with the DC and R1, multiple staff members called the the DC, but were not connecting. When the DC answered the phone, they were unaware the phone was on speaker. The DC answered the phone using expletives and asking why staff were calling. According to a document review, "staff were demanding that
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2025
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 2
Control Number 27-AS-20250130163859
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: 07/29/2025
NARRATIVE
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the DC come in and the DC used more expletives and told them to utilize the medication technicians."

In an interview with this LPA, the DC stated that they had worked a double shift and had gone to bed. When the staff called, they were sleeping and exhausted. The DC went on to state they realized they should not have responded the way they did. "I own my mistakes and I have learned from them."

On 06/07/24, the DC went to the ED and shared that they had spoken inappropriately with their staff when they called the DC at around 11:00PM.

That conversation was documented in a letter the ED provided this LPA. The document was dated 06/18/2024 and it recorded that conversation and also stated that the DC was counseled on proper communication and the need to be an example to the staff. It went on state that the ED would meet with the DC for the next 6 weeks beginning on 06/21/24 to discuss how "they were managing expectations and how they were strategizing ways to communicate properly." The DC successfully completed this process.

Due to the fact that this event happened around 11:00 PM when most residents were in their rooms and/or sleeping, this LPA could not locate any residents who witnessed this event.

The standard for the preponderance of evidence has not been met and the allegation "Facility staff acting unprofessionally in front of residents." was found UNSUBSTANTIATED. A finding of unsubstantiated does not mean that the event did not happen or was not true, it means that there was not a preponderance of evidence to prove that the allegation occurred.

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 was provided along with APPEAL RIGHTS. Exit interview.

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

DATE: 07/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2