347000985-1-6-2026-27-AS-SRIN-DQLVFW-20260123152437

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347000985
Report Date: 01/06/2026
Date Signed: 01/06/2026 04:33:48 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
04/16/2025 and conducted by Evaluator Christina Valerio

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20250416141742

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: 90	DATE:	01/06/2026
		UNANNOUNCED	TIME BEGAN:	11:50 AM
MET WITH:	Brian Walgenbach		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Facility does not ensure staff treat residents with respect.
Facility does not ensure care is being provided when staff come in to “clear the call button.”
Facility does not ensure staff are physically capable of performing their required job duties.
Facility does not ensure that residents get their scheduled showers.
Facility does not ensure that all staff respond to the call buttons in their assigned areas.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to deliver complaint investigation findings. LPA Valerio met with front desk staff and explained the purpose of the visit. LPA was later met by Licensee Brian Walgenbach.

The following has been determined as it relates to the aforementioned allegations.

Allegation: Facility does not ensure staff treat residents with respect

According to the Reporting Party (RP), the facility staff had to participate in an in-service regarding how to treat and approach residents as some residents have been treated curtly.

Continues on LIC 9099 - C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:	DATE: 01/06/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20250416141742

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: 01/06/2026

NARRATIVE

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Based on interviews conducted with four (4) residents, the residents did not express that residents were not treated with respect.

LPA Valerio reviewed facility files. There was a staff member (S1) that was talked to by management staff regarding the way S1 allegedly spoke to a resident. S1 denied the allegation. LPA Valerio attempted to interview S1 but did not receive a call back.

Based on an interview with Administrator Ryan, they had a Resident Rights in-service

Allegation:
Facility does not ensure care is being provided when staff come in to “clear the call button.”

According to the RP, there are staff, specifically staff 1 (S1) who refuse to respond to call lights. The RP also stated that staff who are not direct care staff will come in to clear the lights but do not provide actual care. RP reported that the RP's call light was not answered until an hour and forty minutes later because the staff who answered could not physically assist the resident. When staff were finally available, the staff members said they were busy and "it was no their hall".

LPA Valerio reviewed facility files. Facility files revealed that S1 was written up on multiple occasions for call light response times longer than 15 minutes, S1 not helping other staff members, and S1 not answering call lights.

LPA Valerio reviewed resident council meeting minutes. For the month of February, March, and April, Call lights were one of the many topics discussed. LPA Valerio read a note that stated, ""Staff clear what the executive director termed the "emergency" call button, but may then leave only to assist the resident at a later time. Ryan stated when answering calls, staff have to give emergency needs priority. Revaluating a resident's needs may indicate that instead of relying on the call button, setting a regular time for assistance may be more appropriate.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:	DATE: 01/06/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2026

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20250416141742

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: 01/06/2026

NARRATIVE

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According to staff interviews, all staff, including business office and front desk staff, have pages so they could respond to call alerts.

According to Administrator Ryan, call lights can be answered by any staff member. If the staff member is not a direct care staff, they can determine if the resident is in an emergency situation or if the staff can assist the resident. For example if a resident needed the remote, any staff member can assist the resident.

Allegation:
Facility does not ensure staff are physically capable of performing their required job duties.

According to the RP, the facility allowed Staff 2 (S2) to work when they could not physically do their job. According to the RP, the RP needed two persons to lift RP. However, S2 was unable to do such act and had to wait for two other staff members to assist the RP.

LPA Valerio reviewed facility files. S2 was on schedule as a direct care staff while on a modified work status. Based on interviews conducted, S2 was to work within S2's capabilities. It was understood that S2 would assist staff on shift with their duties while the other staff assisted S2.

LPA Valerio attempted to interview S2; however S2 did not return LPA's call.

Allegation: Facility does not ensure that residents get their scheduled showers.

According to an interviews with residents, 4 out of 5 residents did not disclose anything to support the allegation of resident not receiving their scheduled shower. According to one resident interview, the facility was so short staff, they did not get their shower on Monday and was told they would get their shower on Tuesday. That resident reported they did not get their shower until Saturday that week.

LPA Valerio reviewed facility documentation. The facility has set shower schedule for each resident. Showers vary depending on each resident; however, showers were scheduled for every two to three days. The facility does not have a way to track whether a resident has gotten a shower or not.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:	DATE: 01/06/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2026

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20250416141742

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: 01/06/2026

NARRATIVE

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Allegation: Facility does not ensure that all staff respond to the call buttons in their assigned areas.

LPA Valerio reviewed facility documentation. LPA Valerio reviewed one staff write up that was given on 02/25/25. The staff member was written up for not answering call lights and answering call lights after a long period of time. According to the staff, the staff member would "forget to clear the call button". Another write up shows that a staff was written up for responding to call lights after a 15 minute wait period. That staff stated they have been doing their best and all other staff were busy to help.

Based on resident interviews, staff member have responded to their call lights.

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.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:	DATE: 01/06/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2026

LIC9099 (FAS) - (06/04)

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