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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347000985
Report Date: 12/03/2025
Date Signed: 12/03/2025 04:52:17 PM

Document Has Been Signed on 12/03/2025 04:52 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/
DIRECTOR:		RYAN NAKAOFACILITY TYPE:
740
ADDRESS:3415 MAYHEW ROADTELEPHONE:
(916) 369-8967
CITY:SACRAMENTOSTATE: CAZIP CODE:
95827
CAPACITY: 175CENSUS: DATE:
12/03/2025
TYPE OF VISIT:OfficeANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Ryan Nakao
Payam A. Saljoughian
Brian Walgenbach		TIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On December 03, 2025, a virtual office meeting was held via Microsoft Teams to discuss the Stipulation and Waiver. Present in today's meeting are the following: Community Care Licensing Representatives; Regional Manager (RM) Stephenie Doub, Licensing Program Manager (LPM) Stephen Richardson, Licensing Program Analyst (LPA) Christina Valerio and Facility Licensee representatives;
Counsel of Payam A. Saljoughian of Hanson Bridgett LLP, Executive Director Ryan Nakao, and Licensee Brian Walgenbach.

The purpose of this office meeting was to go over the Stipulation and Waiver for this facility and the Decision and Order that went into effect on 11/14/2025. All of the sections were reviewed with all of the above participants along with all applicable Title 22 Rules and Regulations, Health and Safety Codes, and Government Codes.

Items discussed at the meeting included, but not limited to:
  • Findings
  • Revocation: Stayed with Probation - three (3) years
  • Appeal of $15,000 Civil Penalty Denied
  • Future Application for Licensure, Registration, Certification or Approval
  • Tolling of Probationary Period
  • Completion of Probation
  • Violation of Stipulation Term
  • Department's Authority
Continues on LIC 809- C...
NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Christina Valerio
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/03/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
VISIT DATE: 12/03/2025
NARRATIVE
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Continued from LIC 809
  • Monitoring Fee
  • Waiver of Hearing Rights
  • Waiver of Appeal/Modification Rights
  • Waiver of Claims
  • Severable Terms
  • Public Records
  • Signatures
  • Counterparts
  • Effective Date
  • No Oral Modification


The licensee shall do the following:
  • Facility shall operate in strict compliance with regulations and statutes...
  • Facility shall ensure the facility is clean, safe, sanitary, and in good repair at all times
  • Facility shall post the Stipulation in a conspicuous place at the facility
  • Facility shall report any unusual incident... reported by the next working day and a written report within seven (7) days
  • Facility shall maintain current personnel records of each employee
  • Facility shall submit by December 15, 2025 a detailed procedure for maintaining records to ensure staff have current POLST/DNR orders
  • Facility shall submit by December 15, 2025 the "no smoking:" policy reflected in the plan of operation and admission agreement or addendum thereto...
  • Facility shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items... are in locked storage and are not left unattended
    • Facility shall notify CCL when residents are given access to items.. and provide plan to ensure resident's or other residents' safety
    • Facility shall reassess residents who are given access on a bi-annual basis
  • Facility shall submit by December 15, 2025 a detailed process for the emergency response system and procedures for staff.
  • Facility shall provide monthly training to all facility staff on applicable Title 22 regulations
NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Christina Valerio
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2025
LIC809 (FAS) - (06/04)
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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
VISIT DATE: 12/03/2025
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Community Care Licensing will do the following:
  • Increase facility monitoring to quarterly visits during the probationary period
  • Continue to maintain open communication lines with facility


There were no deficiencies observed or cited at this time.

An exit interview was held via cell phone to go over the contents of this report.

A scanned copy of this report will be emailed to the facility Executive Director Ryan Nakao, who will sign and send back the signed copy to this LPA.

NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Christina Valerio
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2025
LIC809 (FAS) - (06/04)
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