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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347000985
Report Date: 10/14/2025
Date Signed: 10/14/2025 12:45:11 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
01/31/2025 and conducted by Evaluator Kimberly Viarella
COMPLAINT CONTROL NUMBER: 27-AS-20250131102041
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: 92DATE:
10/14/2025
UNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Ryan NakaoTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Facility staff did not do proper reappraisal on resident.
Facility staff did not meet resident hygiene needs.
Facility staff did not notify resident's responsible party of change in condition.
Facility not releasing information about resident that has been requested by responsible party.
Facility staff did not seek medical attention in a timely manner.
INVESTIGATION FINDINGS:
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On 10/14/25, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to deliver the findings for this complaint investigation. 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.

Through a record review, this LPA learned that on 12/17/24, the Medical Power of Attorney (POA) for resident (R1) indicated concerns to the Director of Care (DC) regarding a decline in R1 over the past month. A care conference was scheduled for 12/19/24. On that day, the POA met with the DC and shared their concerns. The POA stated that they, along with a family member (F) and another community resource member (CM), who visited the facility weekly, had noticed the following in the past month: strong urine smell on R1 and in their apartment, R1 not caring for themself, not changing clothes, not regularly bathing based on dry skin, smell, and appearance. The POA went on to mention R1 being unstable on their feet and that the POA had been trying to shift R1 from using a cane to using walker.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025
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 10
Control Number 27-AS-20250131102041
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: 10/14/2025
NARRATIVE
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The POA wanted to know what the process was to increase R1's level of care. According to the POA , the DC stated, "that they would assess R1 for 30 days and after our meeting we will discuss with the Executive Director, (ED) the cleaning staff and laundry to develop extra care plan and then will meet with me (the POA) again after the assessment to discuss level of care." 

This LPA learned through interviews with both the POA and the DC that R1 would not be charged extra at this time without determining the level of care and stated that they would add additional assistance while R1 was being assessed.

On 12/22/24, F called the POA to state that they had not seen any improvements regarding R1.  F went on to state that CR also spoke to F about R1's appearance and urine smell and CR was also concerned about R1's health and well-being.  This LPA interviewed CR on 09/10/25, and they stated, "I noticed that R1 was weaker and slowing down. R1's clothes were disheveled and dirty. I also noticed that R1 smelled like urine. I brought it to the family's attention."

This LPA learned through a review of records that R1 had an unwitnessed fall on 1/17/25 near the common area mailboxes.  According to progress notes in the facility's computer system, R1 bent down to pick something up, and fell. This LPA learned through interviews that staff provided first aid and that R1 was escorted to their room.

This LPA did not learn of any incidents occurring with R1 on 1/18/25, however, on 1/19/25, between 6:00 AM and 7:00 AM, (R1) was found on the floor of their room. It was reported by S1, S3, S4 and S5, that R1 was on the floor beside the bed and in the day clothes worn the day prior. It was also reported that R1 was found covered in urine.
 
LPA reviewed the Physician's Report (LIC 602) for R1. This report was signed and dated 04/12/18 by R1's primary care physician.  It had not been updated in 7 years. The California Code of Regulations (CCR) Title 22 states under Reappraisals, 87463(a)  
"The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first…"  This deficiency has been cited on the LIC 9099 D page. 
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 10
Control Number 27-AS-20250131102041
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: 10/14/2025
NARRATIVE
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Through a review of records, this LPA learned that R1 had been a resident of Golden Pond since 01/26/2008 and while living at the facility had 3 documented falls.  On 06/06/2023, R1 had a "ground level fall coming out of the bathroom in early afternoon; hitting right face against the cat box…" It was also noted that on 06/22/23, right wrist x-ray with increased dorsal angulation and displacement of the intra-articular right distal radius fx; right wrist pain with movement in splint currently…" R1 also had falls on 01/17/25 and 01/19/25. The facility was able to provide internal incident reports documenting these events, however none of these falls were reported to Community Care Licensing (CCL)  as required. This LPA reviewed CCL's electronic files and verified no documentation was present.  R1's care plan should have been updated after the first fall occurred 06/06/23 and a fall prevention plan should have been implemented.  This LPA also learned through the record review that R1 had squamous cell carcinoma removed in 05/2024. This information should have also been included on the LIC 602 and R1's care plan should have been updated to reflect the need for skin checks. 

R1 was sent to the hospital on 01/19/25. Through a review of medical records dated 1/19/2025, R1 was sent out to University California of Davis Hospital. This LPA learned that on page 28 it stated that they found "a 1.5 cm round bloody flesh colored nodule on the left shoulder." A shave biopsy was conducted and on 1/21/25, R1 was diagnosed with basal cell carcinoma on their shoulder. In interviews with the POA and with S9, this LPA learned that R1 had been wearing a sweater in the facility with a stain on the shoulder that the POA stated was from the bleeding lesion on R1's shoulder.

This LPA reviewed R1's care plan. The following notations were at the top of the report: last assessed by the DC on 12/20/24, last modified by the DC on 02/06/25.  R1 never returned to the facility after they were sent out the morning of 01/19/25. LPA observed the following upon reviewing the service plan. On page 2, under #5 it stated "Level of Assistance - Escorts: Independent, resident does not require assistance with escorting." There was no notation that the resident had a history of falls. On page 3, under #7, it stated "Fall potential Low, Resident is at low potential for falls. PERSONALIZE interventions." R1 had a history of 3 documented falls.  Under #11 Dressing, it stated that resident will maintain and/or maximize current level of functioning with dressing with a note that R1 required reminders for dressing by a Caregiver, however through interviews with POA, F, CR, S4, S5, S8, S9, and S10 this LPA learned that R1 was seen wearing soiled clothes. 
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 10
Control Number 27-AS-20250131102041
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: 10/14/2025
NARRATIVE
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The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis…" R1 should have been provided immediate medical assistance and the first person to find R1 on the floor should have called 911.  The department found the above allegation to be substantiated. This deficiency may be found on the LIC 9099D page.

According to the California Code of Regulations, Title 22, all deficiencies associated with the above allegations were cited on the following LIC 9099D pages along with their plans of correction. Any other deficiencies observed or learned of during the course of this investigation will be cited in the case management visit following the conclusion of this complaint investigation.

A copy of this report was provided, along with APPEAL RIGHTS and an exit interview was conducted with Ryan Nakao.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025
LIC9099 (FAS) - (06/04)
Page: 8 of 10
Control Number 27-AS-20250131102041
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: 10/14/2025
NARRATIVE
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Regarding: Facility staff did not notify resident's responsible party of change in condition.

Based on interviews with CR, S1, S3, and S8, staff at Golden Pond had noticed changes in R1's mobility and hygiene. One staff member stated they noticed changes as far back as September of 2024 and that they notified the med tech on duty.  The Wellness Director at the time of this complaint, told the responsible party for R1 that they had contacted R1's primary care physician on 01/18/25, but there were no care notes or documentation recording this call, and the Wellness Director, did not contact the responsible party with this information. According to CCR Observation of the Resident, section 87466, "The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs.  When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any."

Based on the interviews conducted and the review of records, the department finds the above allegation to be Substantiated. This deficiency may be found on the LIC 9099D page.


Regarding: Facility not releasing information about resident that has been requested by responsible party.

This LPA learned through emails provided by the POA that were sent to the Wellness Director, the Director of Care and the Executive Director, that the POA had requested copies of incident reports for 01/17/25 and 01/19/25 on Tuesday, 01/21/25 at 12:20PM and again on Thursday, 01/30/25 at 10:53 AM.  In a separate email On 01/21/25, at 01/21/25, the  POA stated, "I would like to see what changes you have made to R1's care plan during the 30 days. I.e., scheduled in room checks, bathing and dressing schedules, reminder schedules and the progress that has been made."  The POA stated that they never received a response to this email or the information regarding the changes that were added to R1's care plan. The Director of Care stated that they along with the Wellness Director and the Executive Director, had a care conference with the POA on 01/23/25 and thought that everything was clarified during that meeting and they did not follow-up with an email.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 10
Control Number 27-AS-20250131102041
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: 10/14/2025
NARRATIVE
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The POA received the incident reports requested on 02/01/25, 11 days after the initial request on 01/21/25.  This delay in receiving the requested information was a violation of the California Code of Regulations (CCR) 87468.2(a)(19).

Additional Personal Rights of Residents in Privately Operated Facilities:
(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:
(19) To have prompt access to review all of their records and to purchase photocopies of their records.  Photocopied records shall be provided within two (2) business days and at a cost that does not exceed the community standard for photocopies.

This deficiency will be cited during a case management visit following this one.

 This LPA requested documentation (fax confirmation slips or forwarded time stamped emails) that incident reports were sent to Community Care Licensing and to R1's POA. None were provided accurately documenting that these reports were sent out. The incident reports were sent to the POA on 02/01/25 however, no documentation was provided in response to the POA's email request on 02/21/25 regarding their change of care during the 30-day evaluation with regard to showers or assistance with other activities of daily living.  The POA had the right to see the documentation regarding any care being provided to R1.

According to CCR, Resident Records, 87506(c)(1)   
(c) All information and records obtained from or regarding residents shall be confidential.
 (1) The licensee shall be responsible for storing active and inactive records and for safeguarding the confidentiality of their contents.  The licensee and all employees shall reveal or make available confidential information only upon the resident's written consent or that of his designated representative.

Regarding: Facility staff did not seek medical attention in a timely manner.

Based on interviews and a review of documents, a member of the kitchen staff was the first to find R1 "on the floor of their room in a puddle of urine" on 1/19/25 and they contacted a caregiver, who in turn contacted a medication technician to come and assess R1.  According to CCR Incidental and Medical Care, 87465, " (g)
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 10
Control Number 27-AS-20250131102041
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: 10/14/2025
NARRATIVE
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Under #12 Toileting, it stated that, "Resident will maintain and/or maximize current level of functioning with toileting. Requires reminders or minimal use of bedside commode/urinal." During the care conference on 12/19/24, the DC learned that R1 smelled like urine and through interviews this LPA learned that R1 was having "accidents" in public areas. The care plan should have been updated to include a managed incontinence care plan. On page 4, under #14, Special Care, it stated, "Resident will maintain and/or maximize current level of functionality with special care needs. Fall concern." and then "None" was listed. No strategies were listed for addressing fall concerns based on the 3 recorded falls.

Regarding: Facility staff did not do proper reappraisal on resident.

Based on a review of records and interviews, the facility did not do a proper reappraisal of the resident. The Department finds the above allegation to be substantiated. This deficiency may be found on the LIC 9099D page.

Regarding: Facility staff did not meet resident hygiene needs.

This LPA requested the shower logs for R1. The facility provided 1 for 12/25/24 where they checked off that R1 refused a shower and another for 12/28/24 which had a handwritten note that stated "R1 said they already showered this morning." Skin checks were not done on either day and no concerns were noted. Under #9, on page 3 of R1's Service Plan, it stated that "Resident will maintain and/or maximize current level of functioning with bathing; prefers showers. R1 requires standby assistance, 2X per week for bathing. Shower days will be Tuesday and Wednesday." Documentation was not provided that showers were given or refused on R1's scheduled shower days: 12/17/24, 12/18/24, 12/24/24, 12/31/24, 01/01/25, 01/07/25, 01/08/25, 01/14/25, and 01/15/25. According to CCR
Basic Services, 87464, it states, "(f) Basic services shall at a minimum include: (4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications…"

Based on a review of these documents, the department found the above allegation to be substantiated. This deficiency may be found on the LIC 9099D page.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 10
Control Number 27-AS-20250131102041
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: 10/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/15/2025
Section Cited
CCR
87463(a)
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Reappraisals 87463 (a) The pre-admission appraisal...shall be updated in writing as frequently as necessary or once every 12 months....

The Licensee did not met the above requirement as evidenced by:
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The ED stated that since the LPA brought this concern to their attention back in July of 2025 they have reached out to all resident physicians to obtain updated LIC 602's and the DC in conjunction with an outside consultant are reviewing and ensuring that all updated care plans are appropriate.
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Based on file review and interviews R1's last LIC 602 on file was 4/12/18. R1 had 3 documented falls and required more assistance with ADLs. A new appraisal and care plan were not updated to reflect the needed change in care, this posed an immediate risk to the health, safety and personal rights of residents in care.
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This process is ongoing, and the ED will send CCL a written update with how many LIC 602s and care plans still need to be updated by the close of business tomorrow, 10/15/25.
Type A
10/15/2025
Section Cited
CCR
87464(f)(4)
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Basic Services 87464 (f) Basic services... include: (4) Personal assistance and care as needed by the resident and as indicated...

The Licensee did not meet the above requirement as evidenced by:
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The ED stated that he will meet with his management staff to create an improved system to conduct and track resident showers. This will be submitted to CCL at CCLASCPSacramentoRO@dss.ca.gov by the close of business tomorrow, 10/15/25
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Based on a review of shower logs, R1 did was not given showers on 9 of their scheduled days & there was no docu-
mentation to show that R1 refused. When sent to the hospital, a bleeding cancerous legion was found on R1's shoulder. This posed an immediate threat to the health...
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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: 10/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 10
Control Number 27-AS-20250131102041
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: 10/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/15/2025
Section Cited
CCR
87468.2(a)(7)
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Additional Personal Rights of Residents in Privately Operated Facilities 87468.2 (a) In addition to... the elderly shall have...(7) To fully participate in planning their care... The licensee shall provide necessary information... The Licensee did not meet the above requirement as evidenced by:
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ED stated that they will create a communication binder that will be kept in the crossover room that care staff have access to and it will be reviewed by the DC daily. The ED will send a picture of this binder to CCL by the close of business on 10/14/25 at CCLASCPSacramentoRO@dss.ca.gov.
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Based on interviews with CR, S1, S3, and S8, a change in condition was observed priot to the POA bringing it to the DC's, ED's or Wellness Director's attention. It was not communicated to the POA. This posed an immediate threat to the health, safety, and personal rights of residents in care.
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Type B
10/17/2025
Section Cited
CCR
87506(c)(1)
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Resident Records(c) All info shall be confidential. (1) The licensee...The licensee and all employees shall reveal or make available confidential information... his designated representative.
The Licensee did not meet the above requirement as evidenced by:
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The ED stated that he will review and education the department heads on the this regulation to ensure that all requests for documentation are met in a timely manner. This training will be completed by 10/17/25 and the ED will send a signature sheet of partipcants to CCL at CCLASCPSacramentoRO@dss.ca.gov.
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Based on a review of emails supplied by both the ED and the POA, the requested incident reports were not supplied in a timely manner and the written details for the change in care plan were never supplied to the POA. This posed a potential threat to the health, safety and personal rights of residents in care.
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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: 10/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025
LIC9099 (FAS) - (06/04)
Page: 9 of 10
Control Number 27-AS-20250131102041
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: 10/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/15/2025
Section Cited
CCR
87465(g)
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Incidental Medical and Dental Care 87465(g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat...
The Licensee did not ensure the above requirement was met as evidenced by:


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ED stated he will condcut a training to review emergency procedures and this regulation with all staff. ED to condcut all staff on 10/16/25. He will submit an agend to CCL at CCLASCPSacramentoRO@dss.ca.gov by the close of business tomorrow,
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Based on interviews with 3 staff members, the first person who found R1 on the floor in a puddle of urine should have contacted 911. This delay in medical assistance posed an immediate threat to the health, safety and personal rights of residents in care.
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10/16/25 and a signature sheet of attendees on 10/17/25
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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: 10/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025
LIC9099 (FAS) - (06/04)
Page: 10 of 10