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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347000985
Report Date: 08/25/2025
Date Signed: 08/25/2025 11:57:23 AM

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
05/01/2025 and conducted by Evaluator Vincent Moleski
COMPLAINT CONTROL NUMBER: 27-AS-20250501162842
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: 88DATE:
08/25/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Ryan NakaoTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Facility water supply is contaminated
Staff did not follow resident POLST order
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Vincent Moleski and Triel Lindstrom arrived unannounced to follow up on this complaint investigation. LPAs Moleski and Lindstrom met with facility administrator Ryan Nakao and explained the purpose of the visit.

LPA Moleski was not able to contact the initial complainant who made these allegations for explanation. LPA Moleski interviewed multiple staff members, and the only instance any staff were aware of regarding a POLST order which was not followed occurred in September 2023. The Community Care Licensing Division (CCLD) followed up on this incident and issued a Type A citation on 9/26/2023. LPA Moleski reviewed incident reports sent from this facility and did not observe any recent situations wherein this may have occurred.

[continued on 9099-C]
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2025
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 5
Control Number 27-AS-20250501162842
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: 08/25/2025
NARRATIVE
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CCLD received an incident report from this facility on 4/29/25. According to the incident report, a resident (R1) had tested positive for Legionnaire's disease. LPA Moleski spoke with a representative of Sacramento County Public Health, who was not aware of any additional positive tests for residents of this facility.

Nakao provided documentation showing that two additional residents tested negative for Legionnaire's disease. In an interview, R1 said that they had visited a relative's home and were seen at a medical clinic in the days prior to testing positive. This facility secured water testing services through a third-party contractor. These testing results showed no detectable presence of viable Legionella bacteria.

The department has determined the following as it relates to the allegations that the facility water supply is contaminated and that staff did not follow a resident's POLST order:

Based on interviews and record review, the above allegations are UNSUBSTANTIATED, which means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

No deficiencies were cited regarding the above allegations. An exit interview was held and a copy of this report was left with Nakao.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
05/01/2025 and conducted by Evaluator Vincent Moleski
COMPLAINT CONTROL NUMBER: 27-AS-20250501162842

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: 88DATE:
08/25/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Ryan NakaoTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff are fighting in front of residents
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Vincent Moleski and Triel Lindstrom arrived unannounced to follow up on this complaint investigation. LPAs Moleski and Lindstrom met with facility administrator Ryan Nakao and explained the purpose of the visit.

In an interview, Nakao told LPA Moleski that there was an incident wherein two medication technicians (S1 and S4) had an argument while in the facility dining room around the end of April. In an interview, S1 said that they had confronted S4 because they put a resident's blood sugar sensor on incorrectly. According to S1, S4 told S1 to "stay on their own fucking cart" and called them a "faggot." S1 said that they "blew up on" S4 in response, and admitted that "going off on [S4] in front of residents is not cool." In an interview, S5 said that they overheard this incident from an upstairs room. S5 said they heard "bitch this and bitch that," which was "going on in front of the residents." [continued on 9099-C]
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20250501162842
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: 08/25/2025
NARRATIVE
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In an interview, a resident who was in the dining room at the time (R2) said that the staff "got a little loud" in front of other residents.

The department has determined the following as it relates to the allegation that staff are fighting in front of residents:

Based on interviews, the above allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of evidence standard has been met.

This facility is being cited per 22 CCR Section 87468.1(a)(2). An exit interview was held with Nakao. Appeal rights and a copy of this report were left with Nakao.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20250501162842
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: 08/25/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/26/2025
Section Cited
CCR
87468.1(a)(2)
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"(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: ... (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment." This requirement was not met as evidenced by:
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Licensee adressed personal rights during a prior all-staff meeting and agreed to provide LPA Moleski with notes from this meeting.
vincent.moleski@dss.ca.gov
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Based on interviews, residents were not accorded comfortable accommodations on at least one occasion, which poses an immediate health, safety, and/or personal rights risk.
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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: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5