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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347000985
Report Date: 02/14/2025
Date Signed: 02/14/2025 12:25:01 PM

Document Has Been Signed on 02/14/2025 12:25 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: 88DATE:
02/14/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Ryan NakaoTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to open a complaint investigation, but discovered an unrelated deficiency during the course of the visit, to be addressed in this case management report. LPA Moleski met with facility administrator Ryan Nakao and explained the purpose of the visit.

LPA Moleski requested a resident's (R1's) death report. The report indicated that R1 died on 1/12/25. No indication was made on the report that it was sent to the Community Care Licensing Division (CCLD) for review. A review of CCLD records shows no such death report was received via fax. Nakao confirmed that the report was not faxed to CCLD for review.

This facility is hereby cited per 22 CCR Section 87211(a)(1)(A). An exit interview was held with Nakao. Appeal rights and a copy of this report were left with Nakao.
Stephen RichardsonTELEPHONE: (916) 263-4746
Vincent MoleskiTELEPHONE: (559) 365-5294
DATE: 02/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2025
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 02/14/2025 12:25 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: 02/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/18/2025
Section Cited
CCR
87211(a)(1)(A)

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...(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of ... Death of any resident from any cause ..." This requirement was not met as evidenced by:
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Licensee agrees to provide LPA Moleski a written plan to prevent future reporting errors.
vincent.moleski@dss.ca.gov
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Based on record review and interview, a death report was not submitted to CCLD as required per 22 CCR, which poses a potential health, safety, and/or personal rights risk.
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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
Vincent MoleskiTELEPHONE: (559) 365-5294

DATE: 02/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2025

LIC809 (FAS) - (06/04)
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