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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347000985
Report Date: 05/31/2024
Date Signed: 05/31/2024 12:57:17 PM


Document Has Been Signed on 05/31/2024 12:57 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: 93DATE:
05/31/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Amanda FriedmanTIME COMPLETED:
12:23 PM
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On 05/31/24, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to conduct a case management visit. The LPA identified herself upon arrival, stated the purpose of the visit and asked to speak with the Designated Facility Administrator (DFA). LPA met with Amanda Friedman and interviewed her briefly.

DFA contacted Community Care Licensing to alert the office that she would be leaving Golden Pond and that 5/31/24 would be her last day. This case management is regarding the transition that will occur in her absence.

DFA shared that her departure was planned and the Licensee had been advertising for a replacement. During the interim, the Care Director, Misty Wilson, who also had her Administrator's Certificate, would act as the Designated Facility Administrator until a new one could be hired. The DFA stated that based on her conversation with the Licensee, the facility would not have a gap in coverage.

The LPA obtained an updated LIC 308, LIC 500, and resident roster.

According to California Code of Regulations, Title 22, no deficiencies were observed or cited during today's visit.

Exit interview.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2024
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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