347000985-2-11-2026-27-AS-SRIN-DS9MLS-20260317094249

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347000985
Report Date: 02/11/2026
Date Signed: 02/11/2026 08:47:37 AM

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
07/07/2025 and conducted by Evaluator Christina Valerio

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20250707141449

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: 84	DATE:	02/11/2026
		UNANNOUNCED	TIME BEGAN:	07:30 AM
MET WITH:	Ryan Nakao		TIME COMPLETED:	09:00 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Licensee allowed unqualified staff dispensing medication to residents in care.
Staff did not ensure medications were dispensed as prescribed.
Staff did not ensure medications were properly managed for residents in care.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

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

It was alleged that on July 4th, 2025, there were no medication technicians and caregivers had to dispense medications to residents. It was alleged that evening medications were dispensed incorrectly. The reporting party reported that the staff are constantly late on reordering medication.

LPA Kimberly Viarella interviewed staff 1 (S1) on July 7th, 2025. S1 reported that one medication technician called out of work on July 4th, 2025, which prompted the use of a caregiver to administer medications.

Continues on LIC 9099 - C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:	DATE: 02/11/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2026

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 2

Control Number 27-AS-20250707141449

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: 02/11/2026

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

It should be noted that LPA Viarella cited Golden Pond Retirement Community on October 14, 2025 for a similar incident. On September 21, 2025, a medication technician staff called out, which left the facility without a staff, with prior medication training, for the memory care area. Administrator/Executive Director Ryan Nakao administered medications to ensure residents received medications.

LPA Christina Valerio reviewed facility records. LPA Valerio reviewed Electronic Medication Administrator Records (EMAR) for Resident 1 (R1) and Resident 2 (R2). On July 4, 2025 R1 and R2 had all medications administered based on the observation of a medication technician initials on the EMAR. LPA observed Staff 2 (S2) as the person who signed off on their slots. There were no progress notes that indicated that medications were given late or incorrectly.

LPA Valerio reviewed facility staff training records. According to records, S2 had up to date training for medication administration during the month of July. LPA Valerio crossed checked to see if all staff that signed off on the July 2025 EMAR had training. LPA confirmed that all staff had training. However, it should be noted that on the EMAR there was initials MC, which stand for "Med Cart". According to administrator Ryan, when MC is signed off, it means that it is an outside company that comes in to assist.

LPA Valerio observed Medication Technician progress notes that were provided for R1 and R2. LPA Valerio observed staff correspondence with R1 and R1's doctor office regarding new medications. There were no progress notes to specifically indicating a refill for medications. According to Administrator Ryan, the Wellness Director started in July, which has helped the medication room improve.

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: 02/11/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 2