347000985-12-6-2024-27-AS-KGOD-DBQ28C-20241206161007

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347000985
Report Date: 12/06/2024
Date Signed: 12/06/2024 04:10:12 PM

Document Has Been Signed on 12/06/2024 04:10 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 COMMUNITY		FACILITY NUMBER:	347000985
ADMINISTRATOR/ DIRECTOR:	RYAN NAKAO		FACILITY TYPE:	740
ADDRESS:	3415 MAYHEW ROAD		TELEPHONE:	(916) 369-8967
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95827
CAPACITY: 175	TOTAL ENROLLED CHILDREN: 0	CENSUS: 92	DATE:	12/06/2024
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	03:20 PM
MET WITH:	Misty Wilson		TIME VISIT/ INSPECTION COMPLETED:	04:30 PM

NARRATIVE

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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 October 10, 2022, at 8:58 p.m., a resident (R1) pressed the call button to receive help to the restroom. Facility staff failed to respond to R1's call for help in a timely manner, causing R1 to get up on their own. R1 got up, fell, hitting their head on an unknown object. R1 laid on the ground for approximately 35 minutes before staff checked on them. Once staff found R1, they immediately called 911 and AlphaOne was dispatched at 10:49 p.m.

R1 was transported to the hospital and diagnosed with a hip fracture. Staff openly admitted to failing to check on R1 in a timely manner, resulting in R1 falling, which caused R1 to break their right hip. The allegation of Neglect/Lack of Supervision for failure to seek timely medical attention is substantiated as staff failed to provide aid, which resulted in R1 laying on the ground for a prolonged amount of time.

Per R1's care plan, R1 needs assistance with dressing, bathing, and toileting. R1 is a one-person assist. R1 needs escort service to the toilet. R1 called for help. Per records provided to the department, the facility staff did not respond to the call pendant pressed at 8:48 p.m. until 10:22 p.m. which resulted in the resident falling and sustaining an injury.

Report Continued on LIC 9099-C

Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
Kevin Gould	TELEPHONE: (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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At the time the complaint was concluded, an immediate civil penalty was issued for the amount of five hundred dollars ($500) per California Health and Safety Code section 1569.49(c)(1), due to the violations above resulting in resident injury.

The Department concluded an analysis and determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code section 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death or protracted loss or impairment of function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including, but not limited to, hospitalization, surgery, or physical rehabilitation.”

Today, December 6, 2024, the Department will be issuing a civil penalty per Health and Safety Code section 1569.49(f) for a violation that the Department constitutes as serious bodily injury in the amount of ten thousand dollars ($10,000). However, since an immediate civil penalty of five hundred dollars ($500) was previously issued on March 22, 2023, the amount of the civil penalty issued today will be nine thousand five hundred dollars ($9,500).

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-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (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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