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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347000985
Report Date: 09/01/2026
Date Signed: 09/01/2026 04:48:57 PM

Unfounded


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
04/15/2026 and conducted by Evaluator Christina Valerio
COMPLAINT CONTROL NUMBER: 27-AS-20260415153507
FACILITY NAME:GOLDEN POND RETIREMENT COMMUNITYFACILITY NUMBER:
347000985
ADMINISTRATOR:RYAN NAKAOFACILITY TYPE:
740
ADDRESS:3415 MAYHEW ROADTELEPHONE:
(916) 369-8967
CITY:SACRAMENTOSTATE: CAZIP CODE:
95827
CAPACITY:175CENSUS: DATE:
09/01/2026
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Rachelle ReyesTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff did not follow proper admission procedures for resident
Staff did not safeguard resident's medication
Unlawful eviction
Staff falsified documents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christina Valerio and LPA Reza Jamaly arrived unannounced to conduct a complaint investigation. LPAs met with current Administrator Rachelle Reyes, and explained the purpose of the visit.

The investigation included a review of resident files, an interview with staff, and an interview with the responsible party. The following has been determined as it relates to the aforementioned allegations above.

LPA Valerio reviewed the resident facility file for Resident 1 (R1). LPA Valerio reviewed R1's admission agreement, service plan, preplacement appraisal, medication administration record for April 2026, identification and emergency information form, and LIC 602 physician's report.

Continues on LIC 9099 - C...
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2026
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-20260415153507
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: 09/01/2026
NARRATIVE
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LPA Valerio observed the forms to be signed by R1's authorized representative. LPA Valerio observed the preplacement appraisal dated prior to the admission date of R1. LPA Valerio observed the admission agreement signed by the authorized representative and dated one day prior to the admission date.

LPA Valerio observed the resident's admission date and observed R1's MAR. LPA Valerio observed that the resident was provided all prescribed medications, as evidenced by staff signing their initials on the MAR.

LPA Valerio was informed by Staff 1 (S1) that R1 was a new admission and was never provided an eviction notice.

LPA Valerio interviewed R1's authorized representative, which stated R1 was never provided an eviction notice from Golden Pond Retirement Community. R1's authorized representative confirmed the signatures on all documentation and confirm they are valid. R1's authorized representative stated Golden Pond has been a dream compared to R1's previous placement. R1 has been getting all of their medications, eats full meals, gets their laundry completed, and the staff are amazing.


Based on this information, the allegations are unfounded. A finding of unfounded means the allegations are false, could not have happened, or is without a reasonable basis.

Per California Code of Regulations (CCR) - Title 22, no deficiencies are being cited. An exit interview was held, and a copy of this report was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 2