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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347000985
Report Date: 01/22/2024
Date Signed: 01/22/2024 04:37:15 PM


Document Has Been Signed on 01/22/2024 04:37 PM - 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:GOLDEN POND RETIREMENT COMMUNITYFACILITY NUMBER:
347000985
ADMINISTRATOR:AMANDA FRIEDMANFACILITY TYPE:
740
ADDRESS:3415 MAYHEW ROADTELEPHONE:
(916) 369-8967
CITY:SACRAMENTOSTATE: CAZIP CODE:
95827
CAPACITY:175CENSUS: 90DATE:
01/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Amanda FriedmanTIME COMPLETED:
04:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct an annual inspection. LPA Moleski met with facility administrator Amanda Friedman and explained the purpose of the visit.

LPA Moleski reviewed 10 resident files (R1-R10) and 10 staff files (S1-S10). R9's latest LIC 602 was dated June 17, 2022. R9 has dementia, according to the LIC 602. Friedman said R9 does not have a more recent LIC 602.

LPA Moleski toured the facility with Friedman and inspected common areas, the kitchen, bedrooms, bathrooms, and outdoor areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 72 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 115 degrees Fahrenheit, which is within the required range of 105 and 120 degrees.

LPA Moleski observed first aid supplies, fully-charged and up-to-date fire extinguishers, and carbon monoxide/smoke detectors. LPA Moleski observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPA Moleski observed a locking room for the storage of medication. LPA Moleski observed locked closets for the storage of cleaning solutions.

LPA Moleski interviewed five staff members (S8, S10, S11-S13) and five residents (R5, R11-R14).

This facility is being cited per 22 CCR Section 87705(c)(5). An exit interview was held with Friedman. Appeal rights and a copy of this report were left with Friedman.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 01/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2024
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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Document Has Been Signed on 01/22/2024 04:37 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 01/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, R9 did not have an LIC 602 updated annually, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/05/2024
Plan of Correction
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Licensee agrees to either acquire an updated LIC 602 for R9 or to show proof of R9's appointment to complete the LIC 602 by the POC due date.
vincent.moleski@dss.ca.gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 01/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2024
LIC809 (FAS) - (06/04)
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