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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347000985
Report Date: 05/31/2024
Date Signed: 05/31/2024 03:16:08 PM

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
04/25/2024 and conducted by Evaluator Kesha Lewis
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240425143144
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
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Amanda FriedmanTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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9
Staff did not keep facility free of insects.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kesha Lewis arrived at the facility unannounced to deliver complaint findings for the above allegation. LPA was greeted by staff and explained the reason for the visit.

LPA Lewis conducted a facility tour and observation. LPA conducted facility tour with administrator. Observed were facility common areas, various resident rooms, kitchen area and hallways. Facility was observed by LPA to be clean and sanitary. Floors and walls were clean without prominent stains. Facility was observed to contain no foul odors. Food supply was adequate with 7 days of non-perishables and 2 days of perishable items in place. Fire extinguisher was full charged and dated 9-25-23. Room temperature was 71*F. Smoke alarms and carbon detectors are functioning properly. Current census is 93. No obstructions to fire exits noted during today's tour. LPA did not observe any insects in the facility during this visit.

Cont on 9099C page....
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (916) 764-1024
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 27-AS-20240425143144
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: 05/31/2024
NARRATIVE
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Based on LPA'S observations and records received by the facility from a pest company that administers monthly services to the facility the above allegation is UNSUBSTANTIATED, which means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

No deficiencies were cited regarding the above allegation.

Exit interview conducted. Copy of report given.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (916) 764-1024
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
LIC9099 (FAS) - (06/04)
Page: 2 of 2