347000985-12-15-2025-27-AS-SRIN-DPUUUU-20251230145406

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347000985
Report Date: 12/15/2025
Date Signed: 12/15/2025 03:56:00 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
02/13/2025 and conducted by Evaluator Christina Valerio

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20250213140526

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:	12/15/2025
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Ryan Nakao		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Questionable death.
Staff yell at residents.
Staff handle residents in an inappropriate manner.
Staff are under the influence of drugs and alcohol while caring and supervising residents.
Staff engage in sexual activities in the presence of residents.
Staff do no answer resident's call buttons in a timely manner.
Staff do not allow residents access to resident's call buttons

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christina Valerio arrived to the facility to deliver complaint investigation findings. LPA Valerio met with Executive Director Ryan Nakao, and explained the purpose of the visit.

The investigation was conducted by LPA Kimberly Viarella, LPA Vincent Moleski, LPA Christina Valerio, and Investigator A. Blatnick. The investigation consisted of resident interviews, staff interviews, and facility records review. The following has been determined as it relates to the aforementioned allegations.

Allegation: Questionable Death / Staff handle residents in an inappropriate manner.

According to an interview with the Reporting Party (RP), it was alleged that Resident 1 (R1) passed away after being handled roughly by a staff member, Staff 1 (S1). According to a review of the Regional office's facility records, a death report was submitted by the facility for Resident 1 (R1).
Continues on LIC 9099 - C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2025

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-20250213140526

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: 12/15/2025

NARRATIVE

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According to the death report, R1 passed away on 01/12/2025, cause of death was "unspecified protein calories malnutrition with "DM2" as contributions contributing to death. R1 was 101 years of age and on hospice care. LPA Valerio reviewed shower screen logs, which is where staff also log/indicate any skin concerns such as tears, bruises, etc. LPA Valerio did not review any notes that indicated signs or observations of bruising by facility staff. On 12/24/2025, staff notes indicate resident refused a shower, indicated R1 was in pain, and that R1 stated R1 was going to pass and to call R1's son. LPA Valerio reviewed progress shift notes. There was only one note written before R1's passing , which indicated that on 01/02/2025, Alpha One was called due to R1 being unable to speak due to pain. The next note was written on 01/12/2025, which informs how staff found resident in bedroom without vital signs. LPA Valerio reviewed R1's facility file. LPA Valerio did not find any information to corroborate the statement that R1 passed away due to being mishandled by staff.

Allegation: Staff yell at residents

According to an interview with RP, RP heard from other staff that S1 was yelling at R1 and was later banned from assisting R1. According to an interview with Staff 2 (S2), R1 told S2 that staff were mean to R1; however, R1 would never disclose the names of the staff. S2 stated S2 was no aware of anyone yelling at residents, but knows that staff have yelled at S2 in front of residents. S2 stated staff would yell at S2 for asking for help.

According to an interview with Resident 2 (R2), R2 initially stated that no staff have ever yelled at R2. R2 then recalled a time when S3 was close to R2's face speaking loudly. According to an interviews with Resident 3 (R3) - Resident 5 (R5), they did not disclose information regarding staff yelling at them.

LPA Valerio attempted to interview S1; however, LPA never received a callback. S1 no longer works for Golden Pond Retirement Community.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2025

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20250213140526

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: 12/15/2025

NARRATIVE

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Allegation: Staff are under the influence of drugs and alcohol while caring and supervising residents.

It was alleged that S1 had been under the influence of alcohol and drugs while caring for and supervising residents. According to an interview with S1, S1 denied drinking alcohol at the facility and denied snorting a white substance at the facility. S1 admitted speaking to S4 for being hung-over at work.

According to an interview with S3, there was a staff member who was written up in 2022 for drinking at the facility. That staff member was found to have multiple empty bottles of alcohol in their locker. That staff member was terminated in 2025 for attendance issues. S3 reported that it was relayed to S3 that another staff member was smoking marijuana in the back of the facility and received disciplinary action. According to an interview with Staff 7 (S7), S7 has seen many staff "under the influence" many times. S7 has seen S1 come to work hung-over and smelling like alcohol. S7 denied ever seeing S1 snorting a white substance while at work.

Allegation: Staff engage in sexual activities in the presence of residents.

It was alleged that Staff 5 (S5) and Staff 6 (S6) were caught engaging in sexual activities in a resident's room. LPA Moleski sought clarification on the specific incident. It was confirmed that the incident that took place described by RP took place in the facility parking lot, not a resident's room. According to an interviews conducted with facility staff, staff only heard rumors of staff engaging in activities. For example, S2 reported that S2 heard two staff were taking a resident out to the patio and then were seen kissing in front of the resident. S2 does not know the names of the staff or resident. S5 denies ever engaging in sexual activities during work. LPA attempted to interview S6; however, the interview was unsuccessful.

Allegation: Staff do no answer resident's call buttons in a timely manner.

According to an interview with the RP, R1 waited over an hour for R1's call light to be answered. R1 could not be interviewed due to R1 passing away. According to an interview with R2, R2 stated staff take a while to respond to call lights and feel the facility is short staff. R2 states that it could take up to 15 minutes for staff to respond to a call light. R2 believes 15 minutes is too long. If there were an emergency, 15 minutes would be too late.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2025

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20250213140526

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: 12/15/2025

NARRATIVE

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According to an interview with R3, R3 believes the facility is understaffed. R3 stated facility staff respond within “five minutes to an hour and a half.”R3 said the reasoning for late response times are “they always say that someone has fallen, and they were helping them.”R3 does not know how many times facility staff took an hour and a half to respond.

According to an interview with R4, R4 does not believe the facility to be understaffed. R4 presses the pendant and staff respond within minutes. R4 suffered a fall and pressed the pendent. Staff were there immediately after.

According to an interview with R5, R5 stated facility staff respond within “ten minutes" and “sometimes” facility staff can be slow to respond to [R5] but for the “most part,” the facility staff respond quickly.

LPA Valerio reviewed facility call light records. LPA Valerio reviewed 51 pages of call light responses. LPA Valerio found 11 call lights that were answered over 15 minutes long. Times varied between 16 minutes up until 7 hours and 53 minutes. According to an interview with S3, S3 stated that sometimes staff forget to clear the call light, which would explain anything over an hour. S3 stated the facility always encourage staff to respond right away. According to an interview with S2, S2 stated staff would get in trouble if they responded to a call light late. S2 stated S2 tried their best to get to all the call lights, but ,sometimes, would be the only person for the entire floor.

According to Administrator Ryan, the call lights that showed the note "supervision expired" is not the call light response time, and actually is the battery for the door or unit saying it needs to be change or changed soon. LPA Valerio confirmed the note for the 7 hours and 53 minutes call light had the note "supervision expired".

Allegation: Staff do not allow residents access to resident's call buttons.

It was alleged that facility staff hide the resident's call button so that residents cannot press the button. According to the RP, the RP saw R1's pendant sitting across the room. R1 would not be able to move the pendant because R1 was on hospice.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 27-AS-20250213140526

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: 12/15/2025

NARRATIVE

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According to an interview with S2, S2 stated S2 knows forsure that staff would hide pendants, especially for Resident 6 (R6). R6 was known to press the call button frequently and staff hid it so R6 would not press it. S2 stated S2 never hid it, but knew of staff who did. S2 does not know the names of the staff. S2 stated when S2 worked with R1, R1 always had R1's pendant around the neck. LPA Valerio could not interview R6 due to R6 passing away. R1 could not be interviewed due to passing away.

According to an interview with R2, R2 has never had their pendant hidden from them. According to an interview with R4, R4's pendant is located around R4's neck and can easily press it for assistance. According to R5, R5's pendant is located around the neck and has not been hidden by staff.

Based on all the information collected by the Department, although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the allegations occurred, therefore the allegations are UNSUBSTANTIATED. California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. An exit interview was held and a copy of report was left at the facility with Administrator Ryan Nakao.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2025

LIC9099 (FAS) - (06/04)

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