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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347000985
Report Date: 12/06/2024
Date Signed: 12/06/2024 04:08:24 PM

Document Has Been Signed on 12/06/2024 04:08 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: 175TOTAL ENROLLED CHILDREN: 0CENSUS: 92DATE:
12/06/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:20 PM
MET WITH:Misty WilsonTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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On 12/6/24, at 3:20pm Licensing Program Analysts (LPAs) Kevin Gould and Holly Williams conducted an unannounced case management deficiencies inspection to deliver a civil penalty. LPA met with Director of Care, Misty Wilson, and together discussed the Department’s findings.

On June 29, 2023, the department concluded the complaint investigation regarding the following allegations: Questionable Death

The above allegation was substantiated, and the licensee was cited for the following violation of the California Code of Regulations (CCR) Title 22, 87705 (f)(2) Care of Persons with Dementia: The following shall be stored inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

The department has determined the deceased resident had an extensive history as having a preferred activity of smoking. Per family, resident being allowed to continue their preferred activity of smoking was a condition of living at the facility. For several years, the facility allowed the resident to smoke on their balcony unsupervised. Throughout the duration of the residents stay at the facility, the resident was allowed to retain and possess their own cigarettes and lighters and was permitted by the facility to smoke without supervision. The facility continued to provide supervision and care for the resident but not during their preferred activity of smoking. Resident records reviewed by the Department indicate the resident did have a diagnosis of dementia per Physician's Report dated April 26, 2021.



Report Continued on LIC 9099-C.
Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
Kevin GouldTELEPHONE: (619) 672-5924
DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2024
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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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: 12/06/2024
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Per Title 22 Regulations, for residents with a diagnosis of dementia, items such as matches or cigarettes shall be stored inaccessible to residents in care. Per previous interviews conducted by the Department, the former resident’s cigarettes were not stored inaccessible to the resident which resulted in the reported incident on December 27, 2022, and the resident's subsequent death as a result of the injuries sustained.

The Department concluded an analysis and determined that a civil penalty is warranted for the death of a resident as a result of a violation of Title 22 Regulations. Per Welfare and Institutions Code section 1569.49(e): for a violation that the department determines resulted in the death of a resident, the civil penalty shall be fifteen thousand dollars ($15,000).

Today, December, 6, 2024, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49 for a violation that the Department has determined resulted in the death of a resident in the amount of $15,000.

Exit interview conducted. A copy of the report issued. Appeal rights provided. Director of Care, Misty Wilson's signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024
LIC809 (FAS) - (06/04)
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