347000985-11-21-2025-27-AS-SRIN-DNS3QJ-20251125172713

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347000985
Report Date: 11/21/2025
Date Signed: 11/21/2025 03:40:02 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
05/01/2025 and conducted by Evaluator Vincent Moleski

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20250501162842

FACILITY NAME:	GOLDEN POND RETIREMENT COMMUNITY		FACILITY NUMBER:	347000985
ADMINISTRATOR:	RYAN NAKAO		FACILITY TYPE:	740
ADDRESS:	3415 MAYHEW ROAD		TELEPHONE:	(916) 369-8967
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95827
CAPACITY:	175	CENSUS: 89	DATE:	11/21/2025
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Ryan Nakao		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Insufficient staff

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with facility administrator Ryan Nakao and explained the purpose of the visit.

This investigation consisted of interviews, observation, and record review. LPA Moleski interviewed Nakao, seven staff members (S1-S3, S5-S8), five residents (R1-R3, R6, R8). LPA Moleski also received a written statement from one resident’s responsible party (R4’s RP). LPA Moleski reviewed approximately seven months’ (April-Oct.) worth of medication administration records (MARs) for six residents (R3-R8) and reviewed approximately seven months’ worth of incident reports from this facility (May-Nov.).

In an interview in May, Nakao said that cuts to staffing had recently been made because the facility had been over-staffed for some time. [continued on 9099-C]

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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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: 11/21/2025

NARRATIVE

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At that time, Nakao said there were two medication technicians on the AM shift, two on the PM shift, and one on the NOC shift. There are three medication carts for the ~90 residents of this facility.

Several medication technicians and other medication-dispensing staff (S1, S3, S5-S8) reported that there were not enough medication technicians staffed at this facility. S1 said they are unable to make charting notes to document their observations, they are unable to conduct regular audits of medications, they are unable to order medications in a timely manner, and they are unable to regularly take blood pressure for residents, or weigh residents. S3 said they are unable to assess residents for changes in condition, and has occasionally missed medication passes for some residents due to having too many tasks to complete, or given medication late to residents, including R8. S3 said they are unable to check residents’ blood sugar or blood pressure before giving medications, including R3 and R5. S5 said that they have passed medications to residents late due to the current staffing levels. S6 said that they are unable to order medications in a timely manner, and they cannot take care of other administrative tasks. S6 said that, as a result, some medications have not been given to residents. S7 said that medications are passed late due to inadequate staffing, and they do their charting notes late. S8 said that if a medication technician gets called away to assist with care, one medication is responsible for medications for the entire census of residents, which is not sufficient. S8 said that medication has been discovered missing, and residents have not been given their correct doses. S8 said they are unable to order medications in a timely manner, which has led to missed doses for residents.

In an interview in August, Nakao admitted that caregivers, rather than medication technicians, were passing medications to residents some time in July. Nakao said that this was due to medication technicians calling out. Pursuant to Health and Safety Code Section 1569.69, medication technicians are to receive additional training beyond basic caregiver training. Due to this requirement, caregivers are not a sufficient replacement in the event of a shortage of medication technicians in the facility.

This facility has reported numerous medication errors since May, when this complaint was filed, suggestive of a lack of sufficient oversight in the medication room. An incident report dated 5/23/25 indicates that a resident’s supply of Hydrocodone was discovered to be missing 27 pills. An incident report dated 6/5/25 stated that “a bulk of medications were discovered to be out of stock” for 16 residents. The report went on to say that multiple medication technicians had quit unexpectedly. An incident report dated 7/28/25 indicated that R3 self-administered their insulin before the medication technician on duty was able to check R3’s blood sugar. “This constitutes a medication error,” the author of the report wrote. [continued on 9099-C]

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2025

LIC9099 (FAS) - (06/04)

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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: 11/21/2025

NARRATIVE

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An incident report dated 9/15/25 stated that a resident was “totally out of” a certain blood thinning medication, and had no refills stocked. Medication technicians “did not follow through on this,” the author of the report wrote. An incident report dated 10/29/25 stated that two pills of thyroid medication were found in R4’s bed by a personal caregiver and were provided to facility staff for disposal. An incident report dated 11/15/25 indicated that R3 was provided with their morning pills by a medication technician, but the medication technician left without watching R3 take the pills. The resident then left them out in a common area, where they were later discovered by kitchen staff. The above incidents, which were self-reported by this facility, support the claims made by medication technicians in their interviews with CCLD that they have too many tasks to complete due to the current staffing levels, and have been making medication errors directly impacting residents as a result.

A review of several residents’ MARs (R3-R4, R6-R8) between the months of April and October further illustrate multiple unexplained errors in medication management, which have been attributed by facility staff as indicated above as resulting from a lack of staffing. Most of these residents had doses unrecorded in their MARs, with no notes to explain why a dose might not have been provided to the resident at the appropriate time. This facility’s program description which is on file with CCLD states that “each resident’s medication will be charted on a standard medication record, updated and changed as necessary.” 22 CCR Section 87208(a) states that “the licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so.” Therefore, failure to chart in a resident’s MARs is a failure to deliver the extent of services laid out in this facility’s plan of operation. Based on interviews with medication technicians, this failure to accurately and timely chart in residents' records is a direct result of the facility’s current staffing levels.

R3-R8 include residents who were identified by name or room number in interviews as residents who experienced medication errors due to lack of staffing. Errors discovered in these residents’ MARs include, but are not limited to, the following:

R3’s MARs indicate that they were required to take insulin once daily. On May 9, no signature is present ensuring that R3 self-administered this medication. Additionally, on the evening of May 9, no documentation was made indicating that R3’s blood glucose was checked, or that R3 was assisted with their compression tube leggings. Blood glucose and blood pressure readings were not consistently documented in R3’s chart during the month of May, with several days lacking entries.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2025

LIC9099 (FAS) - (06/04)

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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: 11/21/2025

NARRATIVE

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During the month of June, multiple signatures are not present, indicating that several of R3's medications may not have been given to the resident, including vitamin supplements, dementia management medication, diabetes management medication, and insulin. R3’s MARs for July and August each contains days where R3’s blood sugar and blood pressure readings are not recorded. R3’s spouse, R2, who lives with and advocates for R3, said that staffing has not been adequate, and staff have been making errors with R3’s medication as a result.

R4’s RP sent LPA Moleski an email indicating that on September 21, while R4’s RP was visiting, R4 was given their morning medications late because a medication technician had called out. R4’s RP said that they were also informed by a medication technician on September 13 that R4 received their medications late on that date as well. MARs provided to LPA Moleski do not include timestamps showing when medications were passed. However, R4’s MARs do include errors. On April 20, a note made by the medication technician indicates R4 was given their medication late. A note made by the medication technician on duty on May 5 states that “medications and treatments” were “completed in an adjusted timely process due to only 1 med tech working pm shift tonight … we are not going to be having adequate staff some days.” On the evening of June 8, no signature was made indicating R4’s medicated eye drops were given. Two doses of Tums were not signed for on June 8 and June 9, respectively. On June 8, no signature was made to indicate R4’s evening painkiller was provided, and on the morning of June 9, no signature was made to indicate their thyroid medication was provided. On August 30, no signature was made to indicate a dose of Tums was given to R4. On October 12, no signature was made to indicate a vitamin was provided to R4. In an interview, R4’s private caregiver said that they had observed R4’s medications being given late in the mornings, had personally found loose pills left overnight with R4, and said that the facility was understaffed.

R6’s MARs showed a missing signature for many medications on the evening of May 9, such as their beta-blocking medication, their seizure medication, their anti-inflammation medications, their medicated skin cream, and their insulin. Additionally, R6’s blood sugar was not consistently recorded each day. On June 8 and June 22, R6’s MARs did not indicate their evening medications were given, including the same medications as above. Throughout several additional months, R6’s blood glucose levels were not consistently recorded. In an interview, R6 recalled missing doses of their medications on more than one occasion. [continued on 9099-C]

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2025

LIC9099 (FAS) - (06/04)

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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: 11/21/2025

NARRATIVE

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R7’s MARs include a note written by the medication technician on duty on April 20, stating that R7 received their medications late. On May 5, the medication technician on duty signed for R7’s medication pass, but indicated in a note that their antimetabolite medication was ordered and should have arrived the day prior, but it still was on the way. Notes made by PM medication technicians on May 3 and 4 stated that the facility was out of the medication, although signatures presumed to indicate medication passes were recorded during morning shifts. It is unclear based on the documentation whether R7 actually received their medication on these dates. A note on May 31 indicated that staff were still waiting for the pharmacy to fill and deliver this same medication. No signature was present for R7’s evening dose of this medication on May 21, although the medication was marked as discontinued by the following evening. Notes made by medication technicians imply that the medication was not actually discontinued, but merely out of refills. Starting on June 1, administration signatures indicate that R7 was again receiving their antimetabolite medication, although two missing signatures during the month of June suggest missed doses. Additional notes on June 8 and June 16 indicate that staff were once again waiting for the pharmacy to fill and deliver the same medication. Again, it is unclear whether or not R7 was receiving medication between these two dates, as medication technicians continued to sign for administrations, despite the notes indicating there was no medication in stock to provide to the resident.

R8’s MARs show multiple missed signatures for multiple different kinds of medications given at different times of day on June 7-9, including their muscle relaxant, their stool softener, their immunosuppressant, their blood thinner, their anticonvulsant, their antidepressant, their painkillers, and more. On May 18, signatures were missing for midday and evening doses of several medications, including some of the above medications. Between September 4 and September 8, multiple signatures were missing for R8’s painkillers. In an interview, R8 said that the facility is understaffed, leading to long response times and medication administration issues. R8 said there have been several times wherein they have not received their painkillers at all, and other times wherein they do not get their medications on time.

22 CCR Section 87411(a) requires that “Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.” This section furthermore empowers CCLD to “require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents [or] the extent of services provided … require such additional staff for the provision of adequate services.” [continued on 9099-C]

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2025

LIC9099 (FAS) - (06/04)

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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: 11/21/2025

NARRATIVE

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After LPA Moleski read over this report, Nakao said that the issues documented in this report were due to the lack of a nurse in the building, as their previous nurse had gone on extended leave, resulting in medication oversight issues. Nakao said that since hiring a new nurse in July, improvements have been made.

The department has determined the following as it relates to the allegation that there is insufficient staff at the facility:

Based on interviews and record review, 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 hereby cited per 22 CCR Section 87411(a). 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: 11/21/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2025

LIC9099 (FAS) - (06/04)

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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: 11/21/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/25/2025 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411(a): “Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.” This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee contends that corrections have already been made to address the primary issues documented in this report. Licensee agrees to provide LPA Moleski with a written statement identifying what corrections have been made. CCLD may require additional documentation to verify corrections at a later date. Athough this deficiency requires immediate correction, Nakao requested an extension due to the weekend. LPA Moleski granted that extension. vincent.moleski@dss.ca.gov
	8 9 10 11 12 13 14	Based on interviews and record review, there have not been sufficient numbers of staff at this facility to complete all services necessary to meet resident needs, resulting in an immediate health, safety, and/or personal rights risk to clients in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 11/21/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2025

LIC9099 (FAS) - (06/04)

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