347000985-1-6-2026-27-AS-SRIN-DQLVH6-20260123152636

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347000985
Report Date: 01/06/2026
Date Signed: 01/06/2026 04:32:08 PM

Substantiated

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
04/17/2025 and conducted by Evaluator Christina Valerio

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20250417091827

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:	02:15 PM
MET WITH:	Brian Walgenbach		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Facility staff are not dispensing medication as prescribed

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to deliver complaint investigation findings. LPA Valerio met with Licensee Brian Walgenbach, and explained the purpose of the visit.

The following has been determined as it relates to the aforementioned allegation.
Allegation: Facility staff are not dispensing medication as prescribed

It was alleged that a facility staff member attempted to provide incorrect medications to a resident in care. The resident noticed the pills were incorrect and informed the staff member. The resident also stated their spouse's orders for diabetes and blood pressure are not followed correctly by staff.

Continues on LIC 9099 - C...

Substantiated

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)

Page: 1 of 4

Control Number 27-AS-20250417091827

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 an interview conducted by LPA Viarella, a staff member reported that " on 04/17/25, a medtech with the scarf put the sensor on their spouse's elbow and did not take the other one off." A picture of the arm was sent to LPA Viarella for reference. In the picture, it shows a residents arm with a diabetes blood glucose monitor located above the elbow. This was allegedly reported to the Health and Wellness Director by the staff member.

According to a declaration statement obtained by LPA Viarella, it was reported that Staff 1 (S1) mixed up medications for two residents. The two medication technicians were questioned regarding the incident and it was found that S1 was the sole person to make the mistake.

According to an interview conducted with a resident, the resident stated that there have been staff who have made mistakes with their medications; however, it has gotten better.

LPA Valerio reviewed Facility Documentation for Resident 1 (R1), Resident 2 (R2) and Resident 3 (R3). LPA Valerio reviewed the April EMAR for R1. LPA Valerio observed multiple areas where there is a missing hard signature, but there is a wet signature on the printed EMAR. This was not an issue for other medication technician staff working on the same day. R1 had five (5) medications that had a missed hard signature on 04/11 and 04/24 but had a wet signature placed afterwards.

In addition to the five (5) medications, R1 had another medication that had missing signatures on 04/07 ,04/11, 04/19 and 04/25. R1 had scheduled blood pressure checks to be completed every Friday. This was observed to only been done on 04/25/25. There were missing signatures on 04/04, 04/11, and 04/18. The facility is also to fax the monthly reading to the PCP on the last day of the month.

LPA Valerio reviewed Facility EMAR Documentation for Resident 2 (R2) for the month of April 2025. Blood sugar reading are to be done one time per day every week on Wednesday at 10:00 AM. For the month of April, there is no recording listed on the EMAR. LPA Valerio reviewed the EMAR dated 03/01/2025 - 03/31/2025. All medications were signed off as given; however, the order for blood sugar readings, which is to be done every Wednesday, was not signed off as completed. LPA did not observe any notes to indicate why this was not completed or signed off.

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-20250417091827

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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LPA Valerio reviewed Facility EMAR Documentation for Resident 3 (R3). Similarly to R1, R3 had multiple entries that have missing electronic signatures from the same staff member. R3 had an order that was scheduled to be given two times per day at 8AM and 5 PM for five days. There was a missing signature on 04/11/2025. R3 was scheduled to have blood sugar checks in the AM and PM. Am shift was missing signature entries on 04/03, 04/04, 04/10, 04/17, 04/18, 04/24, 04/25, and 04/28. PM shift was missing a blood sugar check entry on 04/25/25.

A signature on the EMAR indicates that the staff on shift gave the medication/completed the doctors' orders.

Based on the above noted information, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8) are being cited on the attached LIC-9099D. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided. An exit interview was conducted, and a copy of the 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)

Page: 3 of 4

Control Number 27-AS-20250417091827

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/06/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/07/2026 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (a) ...(4)The licensee shall assist residents with self-administered medications as needed... This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee stated the facility has conducted medication training with the nurse consultant and hired a new nurse. LPA to receive copies of the training by the due date.
	8 9 10 11 12 13 14	Based on records review of R1, R2, and R3, staff did not complete the medication orders. This poses an immediate health, safety, and personal rights risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

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 appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2026

LIC9099 (FAS) - (06/04)

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