<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347000985
Report Date: 09/16/2026
Date Signed: 09/16/2026 03:27:06 PM

Document Has Been Signed on 09/16/2026 03:27 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 COMMUNITYFACILITY NUMBER:
347000985
ADMINISTRATOR/
DIRECTOR:		RACHELLE REYESFACILITY TYPE:
740
ADDRESS:3415 Mayhew RDTELEPHONE:
(916) 369-8967
CITY:SacramentoSTATE: CAZIP CODE:
958273100
CAPACITY: 175CENSUS: DATE:
09/16/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Administrator (AD) Rachelle ReyesTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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
On 9/16/2026 at 9:20 AM, Licensing Program Analyst (LPA) Reza Jamaly arrived unannounced at the facility to follow up on an incident report involving an allegation of a staff physical abused a resident. LPA met with the staff on duty. Administrator (AD) Rachelle Reyes arrived shortly after.

To investigate the allegation, LPA conducted interviews with residents and facility staff and reviewed relevant records.

During the interview, Resident 1 (R1) reported that Staff 1 (S1) changed R1’s brief in a rough manner, causing pain to R1’s leg and hip. R1 further reported that S1 handled R1 roughly and told R1, “I am sick of your urine smell, it’s disgusting.” R1 reported responding to S1, “I told S1 so, it’s not the right job for you, you should stop working as a caregiver.”

LPA interviewed AD regarding the incident. AD reported that AD was not present when the incident occurred. AD explained that S1 initially reported to Wellness Director (WD) that R1 was being aggressive. WD and a medication technician subsequently went to R1’s room to check on R1. According to AD, R1 reported that R1’s leg and hip were hurting but declined further evaluation.

LPA asked AD whether AD had witnessed any similar behavior by S1 involving residents. AD reported that AD had not witnessed similar behavior. However, AD recalled an incident that occurred several days before the 8/28/2026 incident, while R1 was hospitalized. AD reported hearing a dining room staff member ask S1 when R1 would return to the facility. AD reported that S1 responded, “I hope R1 gets sicker not to get back.”

Continues on LIC 809C...

Stephen Richardson
Reza Jamaly
DATE: 09/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/16/2026
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
Page 2

LPA interviewed Wellness Director (WD) regarding the incident. WD reported that WD went to R1’s room after receiving information regarding R1’s behavior and observed R1 without a shirt. WD assisted R1 with putting the shirt back on. WD reported that R1 then told WD that R1 intended to file a complaint because S1 had handled R1 roughly.

LPA reviewed an incident report dated 7/25/2026 completed by Staff 3 (S3). The report documented that S1 expressed a wish that R1 “gets an infection.”

Based on interviews conducted, records reviewed, and information obtained during the investigation, the evidence established that the facility failed to ensure that care and supervision were provided without physical abuse.

Pursuant to California Code of Regulations, Title 22, a deficiency is being cited during today’s visit.

An exit interview was conducted with Director Rachelle. A copy of this report and the facility’s appeal right were provided to the facility.

NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Reza Jamaly
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2026
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 09/16/2026 03:27 PM - It Cannot Be Edited


Created By: Reza Jamaly On 09/16/2026 at 02:53 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GOLDEN POND RETIREMENT COMMUNITY
FACILITY NUMBER: 347000985

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/17/2026
Section Cited
CCR
87413(a)(2)

1
2
3
4
5
6
7
87413 Personnel - Operations
(a) In each facility:
(2) Care and supervision of residents shall be provided without physical or verbal abuse, exploitation or prejudice.
This requrement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee/Administrator will ensure all direct care staff receive training on preventing physical and verbal abuse, appropriate resident handling techniques, and de-escalation methods.
Administrator will submit a copy of the completed staff training documentation that include training title, date of training and attendance sheet with trainees signature.
8
9
10
11
12
13
14
Based on interviews conducted and records reviewed, facility did not ensure the care is provided to R1 without physical or verbal abuse which poses an immediate health and saftey risks to resident 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.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Reza Jamaly
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2026


LIC809 (FAS) - (06/04)
Page: 4 of 4