347000985-1-22-2026-27-AS-SRIN-DR23CW-20260205170836

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347000985
Report Date: 01/22/2026
Date Signed: 01/22/2026 03:36:02 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
05/28/2025 and conducted by Evaluator Christina Valerio

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20250528153817

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: 86	DATE:	01/22/2026
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Ryan Nakao		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Staff did not ensure that resident was assisted with glucose testing

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to deliver complaint investigation. LPA Valerio met with Administrator Ryan Nakao, and explained the purpose of the visit.

The following has been determined as it relates to the allegation: Staff did not ensure that resident was assisted with glucose testing

According to R1's Assessment dated April 08, 2024, R1 was independent in meal consumption, meaning that the resident could do this on their own. On this assessment, it also indicated that the resident would not be participating in the medication management program, which mean the resident would secure their medications in their room and be responsible for taking medications daily.

Continueson LIC 9099 - C...

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:	DATE: 01/22/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2026

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 6

Control Number 27-AS-20250528153817

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: 01/22/2026

NARRATIVE

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According to R1's LIC 602 - Physician Report dated April 04, 2025, R1 required assistance with medication management and supervision. The report also indicated that the resident had a special diet, "CCHO, NAS Diet, Mechanical soft, thin liquid." According to a search on Google, CCHO is a Consistent Carbohydrate Diet. The LIC 602 also indicated the resident was non ambulatory based on physical condition. According to R1's LIC 602 dated 04/04/2025, line 16C "able to perform glucose testing" neither has a yes or no marked.

On April 14, 2025, According to R1's LIC 602 - Physician Report dated April 22, 2025, R1 was considered Ambulatory, need assistance with medication management (including perform own glucose testing and injections), need assistance with bathing self, need assistance to dress/groom self, is able to feed self, is able to care for own toileting needs, had a special diet of "level 7 dysphagia", and a history of skin condition.

According to R1's facility record, Medication Administration Record, for April of 2025, the EMAR shows a "Vitals Blood Sugar" order. LPA Valerio did not see any entries until April 24, 2025. The first entry was on 8:00 AM fon 04/25/25 but no entry on 04/26 or 04/27. Blood sugar recordings resumed on 04/28, 04/29, and 04/30. The 8:00 PM entry for blood sugar was on 04/24 and completed through 04/30/25.

According to R1's facility record, Medication Administration Record, for May 2025 EMAR -
Blood sugar was not taken and no notes on EMAR for 05/05/25 and 05/10/25 at 8 AM.
EMAR stated that Basalar Kwikpen u-100 insulin was given at 8 AM and 8PM since 04/23/25 and it was dc on 05/13/2025. Based on the review, there was a missing signature on the EMAR on 05/9/2025 8 AM and no observed notes to show why it was not given.

Based on the above noted information, the preponderance of evidence standard has been met, therefore the above allegation is 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: 01/22/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 27-AS-20250528153817

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: 01/22/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/23/2026 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 hired a new Wellness Director (LVN) and has completed in-service training with past and current staff since May of 2025. LPA received copies of training.
	8 9 10 11 12 13 14	Based on records review of R1's EMAR, the licensee did not ensure R1's blood glucose level was checked by staff at 8:00 AM on April 26th and 27th of 2025, which poses an immediate health, safety, and personal rights risk to residents in care.	8 9 10 11 12 13 14	POC cleared during today's visit.
	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: 01/22/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 6

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
05/28/2025 and conducted by Evaluator Christina Valerio

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20250528153817

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:	DATE:	01/22/2026
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Ryan Nakao		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Staff did not ensure resident received adequate nourishment, resulting in malnutrition.
Staff did not ensure resident received sufficient beverages, resulting in dehydration.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to deliver complaint investigation. LPA Valerio met with Administrator Ryan Nakao, and explained the purpose of the visit.

Based on interviews and records review of medical records, R1 went to the hospital on 4/16/2025 to 4/23/2025, a 2nd time from 5/1/2025 to 5/6/2025, and a 3rd time from 5/15/2025 to 5/19/2025. R1 was a resident at Golden Pond Retirement community from 4/11/2025 to 5/19/2025

According to a pre-appraisal conducted by the facility on April 06, 2025, it was stated R1 used a walker, was alert and oriented with mild forgetfulness, and did not need assistance with toileting.

Continues on LIC 9099 - C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:	DATE: 01/22/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2026

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

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 27-AS-20250528153817

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: 01/22/2026

NARRATIVE

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According to R1's Assessment dated April 08, 2024, R1 was independent in meal consumption, meaning that the resident could do this on their own. On this assessment, it also indicated that the resident would not be participating in the medication management program, which mean the resident would secure their medications in their room and be responsible for taking medications daily.

According to R1's LIC 602 - Physician Report dated April 04, 2025, R1 required assistance with medication management and supervision. The report also indicated that the resident had a special diet, "CCHO, NAS Diet, Mechanical soft, thin liquid." According to a search on Google, CCHO is a Consistent Carbohydrate Diet. The LIC 602 also indicated the resident was non ambulatory based on physical condition. According to R1's LIC 602 dated 04/04/2025, line 16C "able to perform glucose testing" neither has a yes or no marked.

According to R1's LIC 602 dated April 22, 2025, the resident was considered ambulatory, able to feed one self, and had a special diet of "level 7 dysphagia".

According to staff interviews, staff provided conflicting dates of when R1 was initially sent out. A staff member stated the resident came on a Friday and then was sent out the next day. Another staff member recalled the resident being here for a few days and then being sent out. A third staff member stated they could not recall the dates.

According to an interview with kitchen staff, they recalled providing sugar free pudding cups for the resident's personal refrigerator. However, this staff also indicated that they were unaware if the resident would be coming down for meals since most residents come down at their leisure. It was observed that R1 was not interested in eating; therefore, the staff brought it up during management meetings to see what could be done.

According to an interview with the Director of Care stated R1 was seen on a Tuesday (for an assessment) then admitted on Thursday or Friday and then sent out one or two days later. The staff believed medications made R1 not hungry and reported that staff can encourage eating but the resident still has a choice.

Continues on LIC 9099-C...

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:	DATE: 01/22/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2026

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 27-AS-20250528153817

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: 01/22/2026

NARRATIVE

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According to an outside agency progress notes, R1 received Home Health services through North Star Home Health. According to outside agency progress notes, which are to be done at every visit, there were entries written on April 14th, 23rd, 29th, and May 1, 2025. On April 14, 2025, Home Health RN wrote "called PCP to report unmanaged pain & request CGM or order ALF staff to check CBGs" On April 29, 2025, Home Health RN wrote, "Please order lidocane patches, continuously remind patient to drink health shake as she has no appetite."

Based on all the information collected by the Department, although the allegation may have happened or is valid, here is not a preponderance of evidence to prove the allegation occurred, therefore this allegation is UNSUBSTANTIATED. California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. 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: 01/22/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2026

LIC9099 (FAS) - (06/04)

Page: 6 of 6