Golden Pond Retirement Community.

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. 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 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... 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 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.

According to an interview conducted by LPA Viarella, a staff member reported that " on 04/17/25, a medtech with the scarf put the sensor on their spouse's elbow and did not take the other one off." A picture of the arm was sent to LPA Viarella for reference. In the picture, it shows a residents arm with a diabetes blood glucose monitor located above the elbow. This was allegedly reported to the Health and Wellness Director by the staff member. According to a declaration statement obtained  by LPA Viarella, it was reported that  Staff 1 (S1) mixed up medications for two residents. The two medication technicians were questioned regarding the incident and it was found that S1 was the sole person to make the mistake. According to an interview conducted with a resident, the resident stated that there have been staff who have made mistakes with their medications; however, it has gotten better. LPA Valerio reviewed Facility Documentation for Resident 1 (R1), Resident 2 (R2) and Resident 3 (R3). LPA Valerio reviewed the April EMAR for R1. LPA Valerio observed multiple areas where there is a missing hard signature, but there is a wet signature on the printed EMAR. This was not an issue for other medication technician staff working on the same day. R1 had five (5) medications that had a missed hard signature on 04/11 and 04/24 but had a wet signature placed afterwards. In addition to the five (5) medications, R1 had another medication that had missing signatures on 04/07 ,04/11, 04/19  and 04/25. R1 had scheduled blood pressure checks to be completed every Friday. This was observed to only been done on 04/25/25. There were missing signatures on 04/04, 04/11, and 04/18. The facility is also to fax the monthly reading to the PCP on the last day of the month. LPA Valerio reviewed Facility EMAR Documentation for Resident 2 (R2) for the month of April 2025. Blood sugar reading are to be done one time per day every week on Wednesday at 10:00 AM. For the month of April, there is no recording listed on the EMAR. LPA Valerio reviewed the EMAR dated 03/01/2025 - 03/31/2025. All medications were signed off as given; however, the order for blood sugar readings, which is to be done every Wednesday, was not signed off as  completed. LPA did not observe any notes to indicate why this was not completed or signed off. 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 LPA Valerio reviewed Facility EMAR Documentation for Resident 3 (R3). Similarly to R1, R3 had multiple entries that have missing electronic signatures from the same staff member. R3 had an order that was scheduled to be given two times per day at 8AM and 5 PM for five days. There was a missing signature on 04/11/2025.  R3 was scheduled to have blood sugar checks in the AM and PM. Am shift was missing signature entries on 04/03, 04/04, 04/10, 04/17, 04/18, 04/24, 04/25, and 04/28. PM shift was missing a blood sugar check entry on 04/25/25. A signature on the EMAR indicates that the staff on shift gave the medication/completed the doctors' orders. Based on the above noted information, the preponderance of evidence standard has been met, therefore the above allegations are 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.

At that time, Nakao said there were two medication technicians on the AM shift, two on the PM shift, and one on the NOC shift. There are three medication carts for the ~90 residents of this facility. Several medication technicians and other medication-dispensing staff (S1, S3, S5-S8) reported that there were not enough medication technicians staffed at this facility. S1 said they are unable to make charting notes to document their observations, they are unable to conduct regular audits of medications, they are unable to order medications in a timely manner, and they are unable to regularly take blood pressure for residents, or weigh residents. S3 said they are unable to assess residents for changes in condition, and has occasionally missed medication passes for some residents due to having too many tasks to complete, or given medication late to residents, including R8. S3 said they are unable to check residents’ blood sugar or blood pressure before giving medications, including R3 and R5. S5 said that they have passed medications to residents late due to the current staffing levels. S6 said that they are unable to order medications in a timely manner, and they cannot take care of other administrative tasks. S6 said that, as a result, some medications have not been given to residents. S7 said that medications are passed late due to inadequate staffing, and they do their charting notes late. S8 said that if a medication technician gets called away to assist with care, one medication is responsible for medications for the entire census of residents, which is not sufficient. S8 said that medication has been discovered missing, and residents have not been given their correct doses. S8 said they are unable to order medications in a timely manner, which has led to missed doses for residents. In an interview in August, Nakao admitted that caregivers, rather than medication technicians, were passing medications to residents some time in July. Nakao said that this was due to medication technicians calling out. Pursuant to Health and Safety Code Section 1569.69, medication technicians are to receive additional training beyond basic caregiver training. Due to this requirement, caregivers are not a sufficient replacement in the event of a shortage of medication technicians in the facility. This facility has reported numerous medication errors since May, when this complaint was filed, suggestive of a lack of sufficient oversight in the medication room. An incident report dated 5/23/25 indicates that a resident’s supply of Hydrocodone was discovered to be missing 27 pills. An incident report dated 6/5/25 stated that “a bulk of medications were discovered to be out of stock” for 16 residents. The report went on to say that multiple medication technicians had quit unexpectedly. An incident report dated 7/28/25 indicated that R3 self-administered their insulin before the medication technician on duty was able to check R3’s blood sugar. “This constitutes a medication error,” the author of the report wrote. [continued on 9099-C] 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 An incident report dated 9/15/25 stated that a resident was “totally out of” a certain blood thinning medication, and had no refills stocked. Medication technicians “did not follow through on this,” the author of the report wrote. An incident report dated 10/29/25 stated that two pills of thyroid medication were found in R4’s bed by a personal caregiver and were provided to facility staff for disposal. An incident report dated 11/15/25 indicated that R3 was provided with their morning pills by a medication technician, but the medication technician left without watching R3 take the pills. The resident then left them out in a common area, where they were later discovered by kitchen staff. The above incidents, which were self-reported by this facility, support the claims made by medication technicians in their interviews with CCLD that they have too many tasks to complete due to the current staffing levels, and have been making medication errors directly impacting residents as a result. A review of several residents’ MARs (R3-R4, R6-R8) between the months of April and October further illustrate multiple unexplained errors in medication management, which have been attributed by facility staff as indicated above as resulting from a lack of staffing. Most of these residents had doses unrecorded in their MARs, with no notes to explain why a dose might not have been provided to the resident at the appropriate time. This facility’s program description which is on file with CCLD states that “each resident’s medication will be charted on a standard medication record, updated and changed as necessary.” 22 CCR Section 87208(a) states that “the licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so.” Therefore, failure to chart in a resident’s MARs is a failure to deliver the extent of services laid out in this facility’s plan of operation. Based on interviews with medication technicians, this failure to accurately and timely chart in residents' records is a direct result of the facility’s current staffing levels. R3-R8 include residents who were identified by name or room number in interviews as residents who experienced medication errors due to lack of staffing. Errors discovered in these residents’ MARs include, but are not limited to, the following: R3’s MARs indicate that they were required to take insulin once daily. On May 9, no signature is present ensuring that R3 self-administered this medication. Additionally, on the evening of May 9, no documentation was made indicating that R3’s blood glucose was checked, or that R3 was assisted with their compression tube leggings. Blood glucose and blood pressure readings were not consistently documented in R3’s chart during the month of May, with several days lacking entries. 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 During the month of June, multiple signatures are not present, indicating that several of R3's medications may not have been given to the resident, including vitamin supplements, dementia management medication, diabetes management medication, and insulin. R3’s MARs for July and August each contains days where R3’s blood sugar and blood pressure readings are not recorded. R3’s spouse, R2, who lives with and advocates for R3, said that staffing has not been adequate, and staff have been making errors with R3’s medication as a result. R4’s RP sent LPA Moleski an email indicating that on September 21, while R4’s RP was visiting, R4 was given their morning medications late because a medication technician had called out. R4’s RP said that they were also informed by a medication technician on September 13 that R4 received their medications late on that date as well. MARs provided to LPA Moleski do not include timestamps showing when medications were passed. However, R4’s MARs do include errors. On April 20, a note made by the medication technician indicates R4 was given their medication late. A note made by the medication technician on duty on May 5 states that “medications and treatments” were “completed in an adjusted timely process due to only 1 med tech working pm shift tonight … we are not going to be having adequate staff some days.” On the evening of June 8, no signature was made indicating R4’s medicated eye drops were given. Two doses of Tums were not signed for on June 8 and June 9, respectively. On June 8, no signature was made to indicate R4’s evening painkiller was provided, and on the morning of June 9, no signature was made to indicate their thyroid medication was provided. On August 30, no signature was made to indicate a dose of Tums was given to R4. On October 12, no signature was made to indicate a vitamin was provided to R4. In an interview, R4’s private caregiver said that they had observed R4’s medications being given late in the mornings, had personally found loose pills left overnight with R4, and said that the facility was understaffed. R6’s MARs showed a missing signature for many medications on the evening of May 9, such as their beta-blocking medication, their seizure medication, their anti-inflammation medications, their medicated skin cream, and their insulin. Additionally, R6’s blood sugar was not consistently recorded each day. On June 8 and June 22, R6’s MARs did not indicate their evening medications were given, including the same medications as above. Throughout several additional months, R6’s blood glucose levels were not consistently recorded. In an interview, R6 recalled missing doses of their medications on more than one occasion. [continued on 9099-C] 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 R7’s MARs include a note written by the medication technician on duty on April 20, stating that R7 received their medications late. On May 5, the medication technician on duty signed for R7’s medication pass, but indicated in a note that their antimetabolite medication was ordered and should have arrived the day prior, but it still was on the way. Notes made by PM medication technicians on May 3 and 4 stated that the facility was out of the medication, although signatures presumed to indicate medication passes were recorded during morning shifts. It is unclear based on the documentation whether R7 actually received their medication on these dates. A note on May 31 indicated that staff were still waiting for the pharmacy to fill and deliver this same medication. No signature was present for R7’s evening dose of this medication on May 21, although the medication was marked as discontinued by the following evening. Notes made by medication technicians imply that the medication was not actually disconti

On 10/14/25, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to conduct a case management to address the deficiencies observed / learned during complaint investigation # 27-AS-20250131102041. LPA identified herself upon arrival, stated the purpose of the visit and asked to meet with the Designated Facility Administrator/Executive Director (ED). LPA met with Ryan Nakao and a brief interview followed. Staff interviewed (S1, S3 and S8) told this LPA that they had observed changes in resident (R1) but there was no written documentation noting these changes. Observation of the Resident 87466 The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This LPA learned during the course of the investigation that staff (S13) were not conducting 2 hour checks. (initials were on the checklist for NOC care staff on the 18th (S13), but resident would not have been on the floor in their daytime clothes and soaked if the checks had been done). The NOC shift caregiver checked off they did 2 hour checks on the 19th and R1 wasn't even in the building - they were at the hospital. 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 CCR 87411 Personnel (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.  In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports.  Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds.  The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. LPA asked the Executive Director (ED) for any internal witness statements that were taken and/or submitted to the ED regarding R1.  The ED stated that they did not have any.  LPA received a copy of a statement that documented observations from that morning when R1 was found. CCR 87207  False Claims No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. While investigating this complaint this LPA was made aware that on Sunday, 9/21/25, the Executive Director, who has not had medication technician training, was administering medications in memory care. CCR 87465(h)(6), Incidental and Medical and Dental Care Staff responsible for assisting residents with self-administration of medications shall receive training as specified in Section 1569 69 of the Health and Safety Code before they assist residents with medications. According to the California Code of Regulations, Title 22, these deficiencies were cited on the following LIC 809D pages. A copy of this report was provided along with APPEAL RIGHTS and an exit interview was conducted with Ryan Nakao.

The POA wanted to know what the process was to increase R1's level of care. According to the POA , the DC stated, "that they would assess R1 for 30 days and after our meeting we will discuss with the Executive Director, (ED) the cleaning staff and laundry to develop extra care plan and then will meet with me (the POA) again after the assessment to discuss level of care." This LPA learned through interviews with both the POA and the DC that R1 would not be charged extra at this time without determining the level of care and stated that they would add additional assistance while R1 was being assessed. On 12/22/24, F called the POA to state that they had not seen any improvements regarding R1.  F went on to state that CR also spoke to F about R1's appearance and urine smell and CR was also concerned about R1's health and well-being.  This LPA interviewed CR on 09/10/25, and they stated, "I noticed that R1 was weaker and slowing down. R1's clothes were disheveled and dirty. I also noticed that R1 smelled like urine. I brought it to the family's attention." This LPA learned through a review of records that R1 had an unwitnessed fall on 1/17/25 near the common area mailboxes.  According to progress notes in the facility's computer system, R1 bent down to pick something up, and fell. This LPA learned through interviews that staff provided first aid and that R1 was escorted to their room. This LPA did not learn of any incidents occurring with R1 on 1/18/25, however, on 1/19/25, between 6:00 AM and 7:00 AM, (R1) was found on the floor of their room. It was reported by S1, S3, S4 and S5, that R1 was on the floor beside the bed and in the day clothes worn the day prior. It was also reported that R1 was found covered in urine. LPA reviewed the Physician's Report (LIC 602) for R1. This report was signed and dated 04/12/18 by R1's primary care physician.  It had not been updated in 7 years. The California Code of Regulations (CCR) Title 22 states under Reappraisals, 87463(a) "The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first…"  This deficiency has been cited on the LIC 9099 D page. 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 Through a review of records, this LPA learned that R1 had been a resident of Golden Pond since 01/26/2008 and while living at the facility had 3 documented falls.  On 06/06/2023, R1 had a "ground level fall coming out of the bathroom in early afternoon; hitting right face against the cat box…" It was also noted that on 06/22/23, right wrist x-ray with increased dorsal angulation and displacement of the intra-articular right distal radius fx; right wrist pain with movement in splint currently…" R1 also had falls on 01/17/25 and 01/19/25. The facility was able to provide internal incident reports documenting these events, however none of these falls were reported to Community Care Licensing (CCL)  as required. This LPA reviewed CCL's electronic files and verified no documentation was present.  R1's care plan should have been updated after the first fall occurred 06/06/23 and a fall prevention plan should have been implemented.  This LPA also learned through the record review that R1 had squamous cell carcinoma removed in 05/2024. This information should have also been included on the LIC 602 and R1's care plan should have been updated to reflect the need for skin checks. R1 was sent to the hospital on 01/19/25. Through a review of medical records dated 1/19/2025, R1 was sent out to University California of Davis Hospital. This LPA learned that on page 28 it stated that they found "a 1.5 cm round bloody flesh colored nodule on the left shoulder." A shave biopsy was conducted and on 1/21/25, R1 was diagnosed with basal cell carcinoma on their shoulder. In interviews with the POA and with S9, this LPA learned that R1 had been wearing a sweater in the facility with a stain on the shoulder that the POA stated was from the bleeding lesion on R1's shoulder. This LPA reviewed R1's care plan. The following notations were at the top of the report: last assessed by the DC on 12/20/24, last modified by the DC on 02/06/25.  R1 never returned to the facility after they were sent out the morning of 01/19/25. LPA observed the following upon reviewing the service plan. On page 2, under #5 it stated "Level of Assistance - Escorts: Independent, resident does not require assistance with escorting." There was no notation that the resident had a history of falls. On page 3, under #7, it stated "Fall potential Low, Resident is at low potential for falls. PERSONALIZE interventions." R1 had a history of 3 documented falls.  Under #11 Dressing, it stated that resident will maintain and/or maximize current level of functioning with dressing with a note that R1 required reminders for dressing by a Caregiver, however through interviews with POA, F, CR, S4, S5, S8, S9, and S10 this LPA learned that R1 was seen wearing soiled clothes. 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 The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis…" R1 should have been provided immediate medical assistance and the first person to find R1 on the floor should have called 911.  The department found the above allegation to be substantiated. This deficiency may be found on the LIC 9099D page. According to the California Code of Regulations, Title 22, all deficiencies associated with the above allegations were cited on the following LIC 9099D pages along with their plans of correction. Any other deficiencies observed or learned of during the course of this investigation will be cited in the case management visit following the conclusion of this complaint investigation. A copy of this report was provided, along with APPEAL RIGHTS and an exit interview was conducted with Ryan Nakao. 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 Regarding: Facility staff did not notify resident's responsible party of change in condition. Based on interviews with CR, S1, S3, and S8, staff at Golden Pond had noticed changes in R1's mobility and hygiene. One staff member stated they noticed changes as far back as September of 2024 and that they notified the med tech on duty.  The Wellness Director at the time of this complaint, told the responsible party for R1 that they had contacted R1's primary care physician on 01/18/25, but there were no care notes or documentation recording this call, and the Wellness Director, did not contact the responsible party with this information. According to CCR Observation of the Resident, section 87466, "The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs.  When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any." Based on the interviews conducted and the review of records, the department finds the above allegation to be Substantiated. This deficiency may be found on the LIC 9099D page. Regarding: Facility not releasing information about resident that has been requested by responsible party. This LPA learned through emails provided by the POA that were sent to the Wellness Director, the Director of Care and the Executive Director, that the POA had requested copies of incident reports for 01/17/25 and 01/19/25 on Tuesday, 01/21/25 at 12:20PM and again on Thursday, 01/30/25 at 10:53 AM.  In a separate email On 01/21/25, at 01/21/25, the  POA stated, "I would like to see what changes you have made to R1's care plan during the 30 days. I.e., scheduled in room checks, bathing and dressing schedules, reminder schedules and the progress that has been made."  The POA stated that they never received a response to this email or the information regarding the changes that were added to R1's care plan. The Director of Care stated that they along with the Wellness Director and the Executive Director, had a care conference with the POA on 01/23/25 and thought that everything was clarified during that meeting and they did not follow-up with an email. 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 The POA received the incident reports requested on 02/01/25, 11 days after the initial request on 01/21/25.  This delay in receiving the requested information was a violation of the California Code of Regulations (CCR) 87468.2(a)(19). Additional Personal Rights of Residents in Privately Operated Facilities: (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (19) To have prompt access to review all of their records and to purchase photocopies of their records.  Photocopied records shall be provided within two (2) business days and at a cost that does not exceed the community standard for photocopies. This deficiency will be cited during a case management visit following this one. This LPA requested documentation (fax confirmation slips or forwarded time stamped emails) that incident reports were sent to Community Care Licensing and to R1's POA. None were provided accurately documenting that these reports were sent out. The incident reports were sent to the P

CCLD received an incident report from this facility on 4/29/25. According to the incident report, a resident (R1) had tested positive for Legionnaire's disease. LPA Moleski spoke with a representative of Sacramento County Public Health, who was not aware of any additional positive tests for residents of this facility. Nakao provided documentation showing that two additional residents tested negative for Legionnaire's disease. In an interview, R1 said that they had visited a relative's home and were seen at a medical clinic in the days prior to testing positive. This facility secured water testing services through a third-party contractor. These testing results showed no detectable presence of viable Legionella bacteria. The department has determined the following as it relates to the allegations that the facility water supply is contaminated and that staff did not follow a resident's POLST order: Based on interviews and record review, the above allegations are UNSUBSTANTIATED, which means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiencies were cited regarding the above allegations. An exit interview was held and a copy of this report was left with Nakao. 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 In an interview, a resident who was in the dining room at the time (R2) said that the staff "got a little loud" in front of other residents. The department has determined the following as it relates to the allegation that staff are fighting in front of residents : Based on interviews, the above allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of evidence standard has been met. This facility is being cited per 22 CCR Section 87468.1(a)(2) . An exit interview was held with Nakao. Appeal rights and a copy of this report were left with Nakao.

completed prior to assisting with the self-administration of medications, and 8 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first 4 weeks of employment." 4 out of the 4 files reviewed did not have documentation to demonstrate that 16 hours of required shadowing had been completed. Through interviews with the Executive Director, this LPA learned that Medication Technicians at this community also provide direct care when needed. For instance, if care staff need assistance with a 2-person lift, and no one else is available, a medication technician was called. They also respond to resident call alerts when instructed to do so. S2 utilized computer software training to complete 4 hours of the required 8 hours of training on the specific topics listed in the Health and Safety Code section 1569.69(a)(4) during their second month of employment. There was a 1 page signature sheet with the heading for Diabetic Monitor Training dated 02/12/25, 7 names were listed but S2's was not. An additional line was added at the bottom with the date 04/24/25 with S2's signature. This occurred beyond the 1-month deadline and there was no agenda included, trainer credential information, or length of duration for the training. There were 2 other handouts with S2's signature in the file, along with an agenda for a staff meeting on 04/29/25, however, the one-page handouts were not on topics that were required as part of the 8 hours of training. A Certificate of Achievement for completing their Medication Technician training was dated 4/01/25, although S2 was hired on 01/22/25. This exceeded the required time frame to complete training by over 2 months. S6 was hired as a Medication Technician on 1/13/23. LPA observed a signed document with S6's name and the initials of the Wellness Director documenting 24 hours of training. The document was dated 03/06/23. Training was not completed within the required time frame. LPA also observed that for 2024, 5.25 hours of online training was completed, none specifically on medication, and therefore did not meet the 8-hour annual refresher training requirement. Records showed that S6 did not begin their medication technician training until 7 months later. They then completed 7 hours of online training specific to becoming a medication technician. This was in violation of the regulations as it was not completed within the required time frame. S6 did not have the required training for a Medication Technician or for staff who assist residents with personal activities of daily living as per California Code of Regulation 87411. LPA was provided a hire date of 08/12/24 for S19. LPA observed that their computer based training totaled 28.75 hours from 08/09/24- 09/18/24. S19 Completed 8 hours of online dementia care training, but not the 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 required 12 during the time frame above. No certificate of completion was included in their file. S19 did not pass the test the first time and at the top was the note "Med Tech was able to answer all questions correct after verbal review on 8/13/24" the day after the exam was administered. A re-test for competency was not conducted. No additional annual computer based training was documented for 2025. Inside S19's file, LPA observed a cover sheet that listed 23 training items, 3 were crossed off and labeled "N/A." There were 11 competency checklists included in the file. 8 of them were signed and dated by their trainer. They did not include the time taken for the training or required 16 hours of shadowing experience and all were dated 8/15/24. The credentials of the trainer were also not included. S19 did not have the required training for a Medication Technician or for staff who assist residents with personal activities of daily living as per California Code of Regulation 87411. S5's date of hire was 10/11/22. S5 moved from working in the kitchen to a position as a Medication Technician on 02/24/25. S5 completed 32.75 hours of Relias training completed from 09/26/23 to 03/17/25. Five hours were specifically related to their position in food service and prior to direct care and medication technician duties, therefore their applicable Relias training totaled 27.75 hours. S5's first 6 hours of dementia care training were not completed prior to providing care. 12 hours were not completed in the first 4 weeks of employment. 40 hours of training were not completed in the first 4 weeks. S5's certificate of completion for med tech training was dated 1/22/25, but the date on the competency exam was 2/5/25. There were handouts regarding hospice, procedures for when a resident has a fall, agendas for staff meetings, ordering medications and more. If they were a part of a training, the date, time/length of training, and facilitator, along with their credentials, were not included. S5 did not have the required training for a Medication Technician or for staff who assist residents with personal activities of daily living as per California Code of Regulation 87411. None of the 4 files reviewed contained First Aid and/or CPR certifications. Health and Safety Code section 1569.618 states that,"(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR." Further, CCR 87411 states that, "(C) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross." 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 Through interviews with S1, S8, and S9, this LPA learned that neither the medication technician staff nor other direct care staff received First Aid or CPR training through a qualified agency. The standard for the preponderance of evidence has been met and the allegation, " Staff are not being properly trained," has been SUBSTANTIATED. This Deficiency has been cited on the LIC 9099 D page. According to the California Code of Regulations, Title 22 no other deficiencies were cited during today's visit, a copy of this report was provided along with APPEAL RIGHTS and an exit interview conducted. 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 In interviews with S19, S4, and S9, there was another instance in the memory care community where S19 gave medications to the wrong resident. This was not documented in S19's file.  According to interviews with S4 and S7 loose pills have been found in the memory care community.  The standard for the preponderance of evidence has been met and the allegation, "Staff mishandle the residents’ medications," has been SUBSTANTIATED. This deficiency has been cited on the LIC 9099 D page. According to the California Code of Regulations, Title 22 no other deficiencies were cited during today's visit, a copy of this report was provided along with APPEAL RIGHTS and an exit interview conducted.

an assessment. Upon reviewing the file for R4, LPA found that it contained a "Health and Service Evaluation" which contained a date in the lower corner, "Monday, May 15, 2023", the document was not on letterhead of any kind and did not contain any names, signatures or dates to indicate where the document came from or who conducted the evaluation. It was noted that it was a return re-assessment, but there were no other comments included as to why the resident was being re-assessed. Handwritten notes contradict the assessment in places: on page 3 the assessor indicated that R4 "requires a 2-person total assistance and/or is incontinent." To the side, a handwritten note was added that stated, "1 person w/t pole." (A T-pole is a floor to ceiling transfer pole or security pole designed to provide additional stability for residents with mobility issues.) LPA observed that there was check mark that R4 was a fall risk, however, no additional status checks were indicated under the section titled, "Additional Status Checks." Under the section pertaining to how many times a day the resident would receive medications, a handwritten note was added, "not sure." On page 4 fall concern was listed as "0" however, on page 6 handwritten notes included "Order" next to gait belt, and next to walker, the notes added were "large walker/order." The last two Physician's Reports (LIC 602s) for this resident dated 4/17/24 and 9/3/24 both stated that R4 was nonambulatory, had mild cognitive impairment, and had a history of seizure disorders. The pre-appraisal for R4 was dated 4/16/24 and the admissions agreement was signed on 4/14/24. Again, one of the tools used to determine if the facility can meet the needs of the resident prior to admissions, was used after the resident had already entered into the contract. LPA requested all appraisals and service plans. The only service plans provided to this LPA were assessed by and modified by S7 on 12/10/24. The plan included signature lines for the resident, the responsible party, and the resident care director. All were blank. LPA reviewed the Physician's Report for R6 dated 9/10/24 which stated that the resident had a diagnosis of Alzheimer's, heart block, urinary retention, Congestive Heart Failure (CHF )and dementia. It stated that R6 required a cardiac diet, had a bladder impairment, auditory and visual impairments, wandering behavior, that R6 was confused and disoriented, able to communicate needs, and able to leave the facility unassisted. It also stated that R6 was unable to bathe and dress themselves, manage their own cash resources and "might require help" with toileting needs. The report also stated that R6 could not independently transfer to and from bed. The physician made a mark under ambulatory and above nonambulatory with a note stating they R6 would need help leaving the facility if there were a fire. The physician described R6's medical condition as 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 "Fair". There were sections in the report that the facility should have gotten clarification on, particularly the fact that the resident with Alzheimer's and dementia was "able to leave the facility unassisted" as well as the resident's ambulatory status. LPA requested updated information regarding this resident and the concerns listed above and the facility was unable to provide any at the time of the inspection. LPA reviewed the care plan for R6 dated 10/15/24. Under "Meal Consumption or Special Care," the required cardiac diet, which was listed on the LIC 602 dated 9/10/24, was not listed as part of R6’s care plan. Again, this care plan included signature lines for the resident, the responsible party, and the resident care director. All were blank. LPA reviewed R5's file and found fax cover sheets to R5's doctor informing the doctor that R5 had fallen. There were 13 separate incidents from 08/01/24 - 01/21/25. LPA reviewed 8 service plans for R5 looking for changes in condition and updates over time. The last 4 were dated 02/08/24, 06/25/24, 01/09/25 and 02/21/25. In every one of these service plans, R5 was listed as a low fall risk. No additional strategies or services were listed to prevent R5 from falling. No additional scheduled checks were included in R5's service plan. The standard for the preponderance of evidence has been met. The allegation: Facility staff are not conducting proper assessments has been SUBSTANTIATED and will be cited on the LIC 9099D page. According to the California Code of Regulations Title 22, no other deficiencies were observed or cited during today's visit. A copy of this report and APPEAL RIGHTS were provided. Exit interview. 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 When interviewed, both staff and residents had mixed responses when asked if there was enough staff to meet the needs of the residents. This LPA learned that there had been call outs but both the Care Coordinator and the Health and Wellness Director stated that they were hands-on and assisted on the floor with residents when needed in order to make up for someone calling out. Interviewees could not provide dates and times of when staffing was insufficient with examples of what needs were not being met during and around the month of August. The standard for meeting the preponderance of evidence was not met and the Department found this allegation UNSUBSTANTIATED. A finding of unsubstantiated means that the allegation MAY have happened or IS valid, but there is not a preponderance of evidence that the alleged violation occurred. According to the California Code of Regulations, no deficiencies were observed or cited during today's visit. A copy of this report was provided, along with APPEAL Rights. Exit interview.

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to open a complaint investigation, but discovered an unrelated deficiency during the course of the visit, to be addressed in this case management report. LPA Moleski met with facility administrator Ryan Nakao and explained the purpose of the visit. LPA Moleski requested a resident's (R1's) death report. The report indicated that R1 died on 1/12/25. No indication was made on the report that it was sent to the Community Care Licensing Division (CCLD) for review. A review of CCLD records shows no such death report was received via fax. Nakao confirmed that the report was not faxed to CCLD for review. This facility is hereby cited per 22 CCR Section 87211(a)(1)(A). An exit interview was held with Nakao. Appeal rights and a copy of this report were left with Nakao.

Unannounced Case Management visit was made by Licensing Program Analyst (LPA) Kimberly Viarella to this facility on 1/29/25 to continue the annual inspection. LPA identified herself upon arrival, stated the purpose of the visit and asked to meet with the Designated Facility Administrator/ Executive Director (ED). LPA met with ED, Ryan Nakao, (certificate # 6066510740 expires on 03/01/25) and a brief interview followed. LPA compared the 41 page Guardian Roster with the 4 page LIC 500 to ensure that all employees had the appropriate background clearances. LPA learned that 3 employees worked in the dining room/ kitchen and were under the age of 18 and constantly supervised. LPA requested documentation for proof of age, Another employee had a name change and LPA provided technical assistance on correcting the name in Guardian. All required employees listed on the LIC 500 were properly cleared at the time of this inspection. LPA inspected the Medication Room. LPA reviewed administration, storage and destruction of medications including the procedures for PRNs. LPA also completed an audit of 1 resident's (R1's) medications to ensure that they were in compliance. The first aid kit was also inspected and LPA observed that it contained all the required elements at the time of this inspection. The Director of Memory Care informed this LPA that new (non-toxic) hand soap dispensers were being installed in all of the memory care units. The Executive Director informed this LPA that additional walkie-talkies were being purchased to improve communication throughout departments so that care staff would respond in a more timely manner going forward. The LPA conducted a file review of 2 staff files and 2 resident files and found that they were complete at the time of this inspection. During this annual inspection, technical assistance was provided regarding the updated dementia care regulations, storage of old resident files, contents of files for agency staff, and a review of personal rights of 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 residents in residential care facilities. According to the California Code of Regulations, Title 22, a deficiency for Basic Services was cited for the lack of response to the call alert activated on 1/28/25 and it was cited on the LIC 809D page. A copy of this report was provided, along with APPEAL Rights and an exit interview was conducted with the Executive Director.

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct an annual inspection. LPA Moleski met with facility administrator Amanda Friedman and explained the purpose of the visit. LPA Moleski reviewed 10 resident files (R1-R10) and 10 staff files (S1-S10). R9's latest LIC 602 was dated June 17, 2022. R9 has dementia, according to the LIC 602. Friedman said R9 does not have a more recent LIC 602. LPA Moleski toured the facility with Friedman and inspected common areas, the kitchen, bedrooms, bathrooms, and outdoor areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 72 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 115 degrees Fahrenheit, which is within the required range of 105 and 120 degrees. LPA Moleski observed first aid supplies, fully-charged and up-to-date fire extinguishers, and carbon monoxide/smoke detectors. LPA Moleski observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPA Moleski observed a locking room for the storage of medication. LPA Moleski observed locked closets for the storage of cleaning solutions. LPA Moleski interviewed five staff members (S8, S10, S11-S13) and five residents (R5, R11-R14). This facility is being cited per 22 CCR Section 87705(c)(5) . An exit interview was held with Friedman. Appeal rights and a copy of this report were left with Friedman.

Licensing Program Analysts (LPA) Kevin Gould made an announced inspection to the Golden Pond Retirement Community on 12/6/23 at 9:00am to conduct a Case Management Deficiencies inspection to address documentation of medication administration. LPA Gould met with Administrator and together discussed the investigation details. While conducting record reviews for an open complaint, LPA observed there was missing documentation on resident's medication administration records (MAR) on July 25, 2023. The facility was not able to provide any information to LPA at the time of inspection as to the cause of missing documentation of the Resident's MAR on the identified date. LPA and Administrator discussed the potential hazards of incomplete medication documentation posed to residents when medications are not documented appropriately. The following deficiency is cited per California Code of Regulations, TITLE 22. Exit interview was conducted with the facility administrator. Appeal Rights were issued, and a copy of this report was left at the facility.

Licensing Program Analyst (LPA) Kevin Gould made an unannounced Case Management Deficiencies inspection to Golden Pond Retirement Community (RCFE) on 11/8/23 at 9:00am to address deficiencies observed during a complaint inspection. LPA Gould met with Administrator Amanda Friedman and together discussed LPA's findings. LPA Gould conducted staff interview regarding resident items that were lost, misplaced or stolen while at the facility. LPA's interviews confirmed that within the last two years of facility operation there have been items go missing (no allegations of theft by facility staff) and were not able to be found or recovered by staff members. LPA Gould reviewed the facility theft loss policy binder and observed no new documentation of items missing since 2014. Based on the interviews and statements obtained and the lack of documentation in the theft loss policy binder; the department has concluded the facility has not followed their own plan of operation and documented theft loss policy per Title 22 regulations. The following deficiencies are cited per California Code Regulation, TITLE 22. Exit interview was conducted with the facility administrator. Appeal Rights were issued, and a copy of this report was left at the facility.

On 10/3/23 at 1:45pm, Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced Case Management Deficiencies inspection to address deficiencies observed by the department related to in the reported incident dated 12/26/22. The department has determined based on a review of evidence collected that the facility did not meet all requirements of Title 22 regulations that were not identified when previously investigated by the department. The department has determined, the facility not adhere to all aspects of dementia care regulations under tittle 22 by allowing a resident with dementia access to cigarettes and matches/lighter which is prohibited under 87705 (care for persons with dementia) sections, f (1) and (2). By allowing the resident with dementia access to cigarettes and lighter/matches, the administrator at the time of the reported incident, did not display knowledge of requirements for the care and supervision on R1 who passed away as a result of injuries sustained while partaking in their preferred activity of smoking. The department has also determined the facility did not meet the basic services for R1 as identified in the Health and safety code in terms of ensuring the general health, safety and well-being for R1 as staff members did not meet regulations for supervision of resident while the resident partook in their preferred activity of smoking which resulted in R1's death from injuries sustained while smoking. Per California Code of Regulations, Title 22 the following deficiencies are cited during today's inspection. An exit interview was conducted, and a copy of this report and appeal rights were left at the facility.

The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation of record keeping is substantiated. The following deficiency is cited per California Code of Regulations, TITLE 22. Exit interview was conducted with the licensee. Appeal Rights were issued, and a copy of this report was left at the facility.

The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation of Questionable Death is substantiated. The following deficiency is cited per California Code of Regulations, TITLE 22. The circumstances of this complaint are being evaluated for enhanced civil penalties by the department. Exit interview was conducted with the facility staff member. Appeal Rights were issued, and a copy of this report was left at the facility.