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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347000985
Report Date: 01/29/2025
Date Signed: 01/29/2025 05:01:10 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/29/2025 05:01 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:
9163698967
CITY:SACRAMENTOSTATE: CAZIP CODE:
95827
CAPACITY: 175TOTAL ENROLLED CHILDREN: 0CENSUS: 87DATE:
01/29/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Ryan NakaoTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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Unannounced Case Management visit was made by Licensing Program Analyst (LPA) Kimberly Viarella to this facility on 1/29/25 to continue the annual inspection. LPA identified herself upon arrival, stated the purpose of the visit and asked to meet with the Designated Facility Administrator/ Executive Director (ED). LPA met with ED, Ryan Nakao, (certificate # 6066510740 expires on 03/01/25) and a brief interview followed.

LPA compared the 41 page Guardian Roster with the 4 page LIC 500 to ensure that all employees had the appropriate background clearances. LPA learned that 3 employees worked in the dining room/ kitchen and were under the age of 18 and constantly supervised. LPA requested documentation for proof of age, Another employee had a name change and LPA provided technical assistance on correcting the name in Guardian. All required employees listed on the LIC 500 were properly cleared at the time of this inspection.

LPA inspected the Medication Room. LPA reviewed administration, storage and destruction of medications including the procedures for PRNs. LPA also completed an audit of 1 resident's (R1's) medications to ensure that they were in compliance. The first aid kit was also inspected and LPA observed that it contained all the required elements at the time of this inspection.

The Director of Memory Care informed this LPA that new (non-toxic) hand soap dispensers were being installed in all of the memory care units.

The Executive Director informed this LPA that additional walkie-talkies were being purchased to improve communication throughout departments so that care staff would respond in a more timely manner going forward.

The LPA conducted a file review of 2 staff files and 2 resident files and found that they were complete at the time of this inspection.

During this annual inspection, technical assistance was provided regarding the updated dementia care regulations, storage of old resident files, contents of files for agency staff, and a review of personal rights of

Stephen RichardsonTELEPHONE: (916) 263-4746
Kimberly ViarellaTELEPHONE: (916) 809-5764
DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 01/29/2025 05:01 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
CCR
87464(f)(4)
Basic Services (f) Basic services shall at a minimum include: (4) Personal assistance and care as needed...with those activities of daily living....

The Licensee did not ensure the above as evidenced by:
Deficient Practice Statement
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POC Due Date: 02/26/2025
Plan of Correction
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The Executive Director stated that 8 pagers were being ordered so that all Care Staff and Managers would carry one. And Alert Logs will be reviewed by Care Director 2X a week and the Executive Director and additional 2X a week for 4 weeks and then reassess if still
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Stephen RichardsonTELEPHONE: (916) 263-4746
Kimberly ViarellaTELEPHONE: (916) 809-5764

DATE: 01/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2025

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: 01/29/2025
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residents in residential care facilities.

According to the California Code of Regulations, Title 22, a deficiency for Basic Services was cited for the lack of response to the call alert activated on 1/28/25 and it was cited on the LIC 809D page. A copy of this report was provided, along with APPEAL Rights and an exit interview was conducted with the Executive Director.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025
LIC809 (FAS) - (06/04)
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