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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347000985
Report Date: 04/01/2022
Date Signed: 04/01/2022 04:40:18 PM

Document Has Been Signed on 04/01/2022 04:40 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:GOLDEN POND RETIREMENT COMMUNITYFACILITY NUMBER:
347000985
ADMINISTRATOR:LUPE RAMIREZFACILITY TYPE:
740
ADDRESS:3415 MAYHEW ROADTELEPHONE:
(916) 369-8967
CITY:SACRAMENTOSTATE: CAZIP CODE:
95827
CAPACITY: 175CENSUS: 110DATE:
04/01/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Tracy McLinnTIME COMPLETED:
04:45 PM
NARRATIVE
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On 4/1/22 at 1:30pm Licensing Program Analyst (LPA) Kevin Gould arrived at Golden Pond Retirement Community for the purpose of addressing an incident report regarding a resident elopement dated 3/27/22. LPA met with newly appointed administrator Tracy McLinn, who has yet to be confirmed by the department.

LPA and staff member McLinn conducted a walk-through of the memory care unit and observed three exterior doors, two doors lead to the fenced and locked patio and one door leads to the exterior of the property. LPA observed two of the doors with delayed egress and one door without. All doors are equipped with alarms. Staff informed LPA that a new alarm was installed on one exterior door because the sound was very low and not audible to all staff on the unit floor. LPA was shown where R1 was able to move a chair to the fence line and used an exterior lighting structure to get over the fence sometime between 11:30am and 12pm on 3/27/22. LPA was informed in the report and by staff that R1 has a history of eloping from other facilities and is intent on leaving each day. R1 also attempted to elope from the facility earlier in the day and was redirected by staff. Her absence was noted and facility contacted family and Sacramento Sheriffs to report a missing person. R1's physician evaluation states she cannot leave the facility unassisted. R1 was returned to the facility the following day after being located by Sacramento PD and returned to the facility by family. Staff informed LPA that due to R1s extended absence from the facility without medication R1 was sent to the hospital to be medically cleared and evaluated. R1 returned the same day. R1 is currently on 30 minute checks by staff. Facility also had R1's medication evaluated for effectiveness by her primary care physician. Facility has received new medication orders for R1. R1's family has provided R1 with an "Apple Air Tag" necklace to more easily locate R1 should she manage to elope from the facility again.

Based on LPAs observations, documents reviewed and statements obtained the following deficiency is cited per California Code of Regulations, Title 22. Exit interview conducted a copy of this report and appeal rights were to the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE: DATE: 04/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/01/2022
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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Document Has Been Signed on 04/01/2022 04:40 PM - It Cannot Be Edited


Created By: Kevin Gould On 04/01/2022 at 04:16 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: GOLDEN POND RETIREMENT COMMUNITY
FACILITY NUMBER: 347000985

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/04/2022
Section Cited
CCR
87705(k)(6)

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 Care of Persons with Dementia: Without violating Section 87468, Personal Rights, facility staff shall ensure the continued safety of residents if they wander away from the facility. This requirement was not met as evidenced by R1's elopement from the facility without staff knowledge on 3/27/22 and was without staff supervision or support for
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 Facility will submit written plan of correction including: a medication and physical re-evaluation for R1 with new orders. R1 is now on 30 minute checks by staff and should be in visual contact if not in her room resting. Facility has removed all unsecured chairs from the patio and will re-evaluate what seating could be included
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over 24 hours until located and returned to the facility which poses an immediate health, safety and persoanl rights risk to resident in care.
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that reduce the danger of a resident using them to elope from the facility.

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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.
SUPERVISOR'S NAME:Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME:Kevin Gould
LICENSING EVALUATOR SIGNATURE:
DATE: 04/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/01/2022


LIC809 (FAS) - (06/04)
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