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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347000985
Report Date: 11/24/2021
Date Signed: 11/24/2021 03:24:56 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:GOLDEN POND RETIREMENT COMMUNITYFACILITY NUMBER:
347000985
ADMINISTRATOR:STEPHEN SARINEFACILITY TYPE:
740
ADDRESS:3415 MAYHEW ROADTELEPHONE:
(916) 369-8967
CITY:SACRAMENTOSTATE: CAZIP CODE:
95827
CAPACITY:175CENSUS: 103DATE:
11/24/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Lupe Ramirez, AdministratorTIME COMPLETED:
03:30 PM
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On 11/24/21 at 1:30pm Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced case management inspection to address concerns regarding a self reported theft of a residents valuables. LPA Gould met with the administrator, Lupe Ramirez and together discussed the steps the facility has taken to address the resident's concerns.

LPA Gould conducted interviews with S1 and R1 (see confidential names list, LIC 811 dated 11/24/21) and will conduct additional interviews on a later date.

Based on the interviews and documentation received, the department will continue to investigate and this case management will remain open at this time.

Per California Code of Regulations, Title 22, there were no deficiencies observed or cited during today's inspection. An exit interview was conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 11/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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