Golden Pond Retirement Community

We haven’t transcribed this report yet. The complete document is on the state’s site.

Type of visit: Case Management - Incident

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... 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.the state’s words, verbatim · CDSS document, Sep 16, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87413(a)(2) · Plan of correction due date: Sep 17, 2026

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: 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.the state’s words, verbatim · CDSS document, Sep 16, 2026

Plan of correction: 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.

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Christina Valerio and CDSS Labor Relations V. Andrade arrived unannounced to conduct a quarterly case management visit. The facility is currently operating under a probationary licensed due to a Stipulation Waiver and Order effective November 14, 2025. LPA Valerio met with Administrator Rachelle Reyes, and explained the purpose of the visit. LPA Valerio, CDSS Labor Relations V. Andrade, and Administrator Rachelle Reyes toured the facility to ensure compliance with the Stipulation and Title 22 regulations. LPA Valerio observed all areas of the facility. The licensee shall do the following during their probationary period: Facility shall operate in strict compliance with regulations and statutes... Facility shall ensure the facility is clean, safe, sanitary, and in good repair at all times Observation during today's visit: LPA observed the facility to be clean with no odors. LPA observed bedrooms on the AL and MC care side to be clean, free from odors, fully furnished, and without hazards. Facility shall post the Stipulation in a conspicuous place at the facility Observation during today's visit: LPA observed the stipulation posted by the lobby elevator. Facility shall report any unusual incident... reported by the next working day and a written report within seven (7) days Observation during today's visit: LPA Valerio has received incident reports for facility through the RO email and Fax Facility shall maintain current personnel records of each employee Continues on LIC 809 - C... Facility shall submit by December 15, 2025 a detailed procedure for maintaining records to ensure staff have current POLST/DNR orders. LPA received documents on December 5, 2025 Facility shall submit by December 15, 2025 the "no smoking:" policy reflected in the plan of operation and admission agreement or addendum thereto...LPA received documents on December 5, 2025 Facility shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items... are in locked storage and are not left unattended Observation during today's visit: LPA Valerio observed the Memory Care side to be free from hazardous items. Facility shall notify CCL when residents are given access to items.. and provide plan to ensure resident's or other residents' safety Observation during today's visit: Administrator Rachelle was informed of the policy and no new updates at this time Facility shall reassess residents who are given access on a bi-annual basis Observation during today's visit: Administrator Rachelle and staff are currently working on residents re-assessments Facility shall submit by December 15, 2025 a detailed process for the emergency response system and procedures for staff. LPA received documents on December 5, 2025 Facility shall provide monthly training to all facility staff on applicable Title 22 regulations Observation during today's visit: Theft and Loss Policy and Professionalism & Accountability conducted by First Call Hospice 05/21/2026, Pressure sores conducted by First Call hospice and Dehydration and Hydration 06/18/2026, Challenging Behaviors conducted with Bristol Hospice and Emergency Protocols 07/16/2026, Communication, Elopement Drill, Fire Drill, Active Shooter Training 08/20/2026 Per California Code of Regulations (CCR) - no deficiencies were cited during today's visit. An exit interview was held, and copy was provided.the state’s words, verbatim · CDSS document, Sep 11, 2026

Allegation investigated: Staff did not follow proper admission procedures for resident Staff did not safeguard resident's medication Unlawful eviction Staff falsified documents

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 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.the state’s words, verbatim · CDSS document, Sep 1, 2026 · control 27-AS-20260415153507

Type of visit: Collateral

An unannounced case management visit made out to the facility on 05/13/2026, by Licensing Program Analyst Pang Lee who was met by Business Office Manager (BOM), Pamela Foy. The current census is 88 LPA Lee explained the purpose of this case management visit was to interview a resident, R1 in regard to a compliant control # 27-AS-20260226152218 that is unrelated to this facility. Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was conducted with BOM Foy, and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 13, 2026

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct a quarterly case management visit. The facility is currently operating under a probationary licensed due to a Stipulation Waiver and Order effective November 14, 2025. LPA Valerio met with designated staff Misty Wilson, and explained the purpose of the visit. LPA Valerio and designated staff Misty toured the facility to ensure compliance with the Stipulation and Title 22 regulations. LPA Valerio observed all areas of the facility The licensee shall do the following during their probationary period: Facility shall operate in strict compliance with regulations and statutes... Facility shall ensure the facility is clean, safe, sanitary, and in good repair at all times Observation during today's visit: LPA observed the facility to be clean with no odors. LPA observed three bedrooms, all of which were in clean, fully furnish, and free from odors. Facility shall post the Stipulation in a conspicuous place at the facility Observation during today's visit: LPA observed the stipulation posted by the lobby elevator. Facility shall report any unusual incident... reported by the next working day and a written report within seven (7) days Observation during today's visit: LPA Valerio has received incident reports for facility through the RO email and Fax Facility shall maintain current personnel records of each employee Continues on LIC 809 - C... Facility shall submit by December 15, 2025 a detailed procedure for maintaining records to ensure staff have current POLST/DNR orders. LPA received documents on December 5, 2025 Facility shall submit by December 15, 2025 the "no smoking:" policy reflected in the plan of operation and admission agreement or addendum thereto...LPA received documents on December 5, 2025 Facility shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items... are in locked storage and are not left unattended Observation during today's visit: LPA Valerio observed three resident bedrooms. Rooms were observed to be clean, organized, and free from any hazardous items. Facility shall notify CCL when residents are given access to items.. and provide plan to ensure resident's or other residents' safety Observation during today's visit: Designated Staff stated there is one resident who has an updated LIC 602 that reflects such information. Facility shall reassess residents who are given access on a bi-annual basis Observation during today's visit: No new updates at this time Facility shall submit by December 15, 2025 a detailed process for the emergency response system and procedures for staff. LPA received documents on December 5, 2025 Facility shall provide monthly training to all facility staff on applicable Title 22 regulations Observation during today's visit: Urinary Care Catheter Care in-service was conducted 02/11/2026, Fire Drill in-service was conducted 02/19/2026, Dinning Room Standard + Personal Hygiene conducted on 03/05/2026, Dementia Training in-service on 03/19/2026, End of Life Care in-service conducted on 03/26/2026, Hydration and Fluid Restrictions in-service conducted on 04/02/2026, Postural Supports & Residents personal rights in-service held on 04/16/2026, Safety and sanitation in-service on 05/07/2026. Per California Code of Regulations (CCR) - no deficiencies were cited during today's visit. An exit interview was held, and copy was provided.the state’s words, verbatim · CDSS document, May 11, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct an annual required inspection. LPA Valerio met with Administrator Ryan, and explained the purpose of the visit. LPA Valerio and Administrator toured the facility to ensure compliance with Title 22 regulations. LPA Valerio observed two resident rooms on the assisting living side and one on the memory care side. The resident rooms were observed fully furnished, free from odors, and clean. LPA did not observed any medications, sharps, or toxins to be left unlocked or accessible to residents in care. The faucet located in the resident room was measured to deliver hot water at a temperature of 111.3 degree F, which is within the regulatory range of 105.0 - 120.0 degrees. LPA Valerio observed residents in the common areas of the facility watching performances, eating charcuterie snacks, and playing bingo. Staff were observed assisting residents, walking in the facility, and doing daily work tasks. LPA Valerio observed the facility fire extinguishers to be fully charged and serviced. The date of the last fire/emergency disaster drill was 02/19/2026. Common areas were observed to be clean and fully furnished. LPA Valerio did not observe any emergency exits to be obstructed. The door that was in disrepair in past visits was observed to be in working condition with the open/closing mechanism to be fully operational. LPA Valerio rode in two elevators, which was observed to be in working condition with no issues. Due to time constraints, LPA Valerio was unable to review resident or staff files. LPA will return at a later date to review the files and complete the annual visit. LPA Valerio requested the following be sent for the facility file: LIC 500, LIC 308, LIC 309, LIC 610, and copy of liability insurance. Per California Code of Regulations (CCR) - no deficiencies were observed during today's visit. An exit interview was held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 27, 2026

Allegation investigated: 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.

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 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.the state’s words, verbatim · CDSS document, Feb 11, 2026 · control 27-AS-20250707141449

Allegation investigated: Staff do not ensure facility is cleaned properly

Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct a complaint investigation. LPA Valerio met with Administrator Ryan and explained the purpose of the visit. It was alleged that the facility does not clean properly. The facility staff leave garbage cans in the hallway, do not vacuum, and the walls are greasy. LPA Valerio toured the facility for personal observation and to conduct interviews. LPA observed 3 housekeeping staff and one person doing laundry. LPA Valerio observed housekeeping staff cleaning bedrooms, cleaning the carpets, and vacuuming the hallways. LPA observed housekeeping carts to have cleaning supplies, hygiene supplies, and an area to throw away garbage. LPA did not observe any garbage in the hallways. The walls did not feel greasy. The common areas appeared to be clean and free from odors. Continues on LIC 9099 - C... Unsubstantiated Bedroom 1: The apartment was fully furnished with no odors. LPA saw a sign on the door that stated that laundry and housekeeping was scheduled for Tuesday for their room. LPA did not observe any dust on their china cabinet that housed items and picture frames. LPA Valerio observed the two bedrooms to be clean without odors. The beds were fully made. There were no clutters. LPA observed the kitchen to be clean without any hazardous items and no dirty dishes. Bedroom 2: Bedroom was a one bedroom apartment. their was no clutter, the bed was made, and their were no odors. Bedroom 3: LPA Valerio observed the bedroom. It is a one bedroom apartment. LPA did not smell any odors. LPA observed the room to have clean floors and the beds were made. Bedroom 4: LPA Valerio observed the room to have a distinct bodily fluid smell. However, the room was not cluttered and the bathroom was cleaned. The resident in the room appeared to be content and happy with the facility. Administrator stated that they have cleaned the room by adding extra cleaning days, implemented a shampoo carpet cleaning, and updating the conservator regarding the status of the condition. Bedroom 5: This bedroom was observed to have a cat. LPA did not feel like the bedroom smelled like cat litter. The bed was not made but it appeared that the resident may have just left for lunch service. The living room area was well kept. Bedroom 6: LPA Valerio observed the studio apartment to be fully furnished. The room was observed to have multiple cups and To go food trays near the door way and by the resident's bedside. The administrator stated that the resident prefers that these are left there because the resident wants to keep them. The staff will come in and tell the resident they need to clean it up and the resident will allow it at times. The staff will come take the garbage out and inform the resident that it is unsafe to keep food from the previous day. Bedroom 7: LPA Valerio observed his room to be clean without odors. His room was set at a cooler temperature. There were no signs of clutter. The room appeared to be freshly vacuumed as evidenced by the vacuum lines on the carpet. The bathroom did not have any stains. The rugs did have dark stains on a small section near the front entrance where people enter the bedroom. 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. An exit interview was held, and a copy of report was left at the facility.the state’s words, verbatim · CDSS document, Feb 4, 2026 · control 27-AS-20260203091728

Allegation investigated: Staff did not administer medication to a resident in care. Staff did not ensure that residents medications were ordered in a timely manner.

Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to deliver complaint investigation findings. LPA Valerio met with Administrator Ryan Nakao, and explained the purpose of the visit. It was alleged that resident's medications were not ordered in a timely manner and that the staff did not give a resident medication for two days. According to the reporting party, the RP states that it is the seventh (7th) time the facility has failed to order medications in time. The RP has brought this concern up with the Executive Director; however, it continues to occur. The following has been determined as it relates to the aforementioned allegations. LPA Valerio reviewed facility records for four (4) resident. Facility records included the Electronic Medication Administration Record (EMAR), Progress Notes, and Fax Communication with Doctors. Unsubstantiated Resident 1 (R1) had a paper MAR and an EMAR for review. On the EMAR, there were medications that had missing signatures on September 5, 8,13,20, 26; however, there were medication technician notes that showed that the medications were given and the charting was done late. For Resident 2 (R2), R2 had all medications signed off for except for two blood sugar readings. there were no notes on the end pages to indicate why the sugar readings were not done; however, medications related to diabetes, such as insulin and glipizide were given on those dates and times. LPA Valerio reviewed correspondence between the facility and the doctor's office. LPA only saw correspondence regarding insulin and glucose readings. According to a progress note written by staff, R2 had an expired glucose sensor on their arm that was not replaced by staff. According to the staff, the administrator corrected the issue. For Resident 3 (R3), R3 had zero missed medications for this time frame; all medications were signed off by staff members for the month of August and September. LPA Valerio reviewed correspondence between the facility and the doctor's office. LPA was provided three pages. One note showed a new order that was dated by the doctor on August 14, 2025. A sticky note written by staff, Noted & Charted & Updated Sunday 08/24/2025…" LPA Valerio reviewed a progress note written by staff, which stated that staff admitted to giving an inhaler to R3 and it was nearly empty, and there was not another one in back up for use. Staff reported to order it that same day and the Administrator went to go pick up the medication. For Resident 4 (R4), R4 had all medications signed off for. R4 had a few entries that were questionable as to whether the facility had the medications or not. For example, ferrous Sulfate Oral Tablet is to be given 1 tablet by mouth twice per day. On September 20, 2025 at 5:00 PM, staff stated the "Drug was not available". On September 21, 2025 at 8:00 AM, staff stated the "Drug was not available", however, at 8:00 PM on September 21, 2025, staff signed off stating that the medication was given. On September 22, 2025 at 8:00 AM, staff stated the "Drug was not available", however, at 8:00 PM on September 22, 2025, staff signed off stating that the medication was given. According to facility staff, the facility implemented a policy in September of 2025: Two med techs are assigned per medication cart to do daily inventory of each cart and any/all medication MUST be refilled when there is only 12 days remaining. 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.the state’s words, verbatim · CDSS document, Jan 26, 2026 · control 27-AS-20250924153705

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct a quarterly case management visit. The facility is currently operating under a probationary licensed due to a Stipulation Waiver and Order effective November 14, 2025. LPA Valerio met with Administrator Ryan Nakao, and explained the purpose of the visit. LPA Valerio and Administrator Ryan toured the facility to ensure compliance with the Stipulation and Title 22 regulations. LPA Valerio observed all areas of the facility The licensee shall do the following during their probationary period: Facility shall operate in strict compliance with regulations and statutes... Facility shall ensure the facility is clean, safe, sanitary, and in good repair at all times Observation during today's visit: LPA observed the facility to be clean with no odors. LPA observed three bedrooms, all of which were in clean, fully furnish, and no odors. Facility shall post the Stipulation in a conspicuous place at the facility Observation during today's visit: LPA observed the stipulation posted by the lobby elevated. Facility shall report any unusual incident... reported by the next working day and a written report within seven (7) days Observation during today's visit: LPA Valerio has received incident reports for facility Facility shall maintain current personnel records of each employee Observation of personnel records: Administrator Ryan has updated personnel records Facility shall submit by December 15, 2025 a detailed procedure for maintaining records to ensure staff have current POLST/DNR orders - LPA received documents on December 5, 2025 Facility shall submit by December 15, 2025 the "no smoking:" policy reflected in the plan of operation and admission agreement or addendum thereto... - LPA received documents on December 5, 2025 Facility shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items... are in locked storage and are not left unattended Observation during today's visit: LPA Valerio observed two rooms in the assisted living and one room in memory care. LPA Valerio also observed all common areas on both floors of the facility. No health or safety issues noted. Facility shall notify CCL when residents are given access to items.. and provide plan to ensure resident's or other residents' safety Observation during today's visit: No new updates at this time Facility shall reassess residents who are given access on a bi-annual basis Observation during today's visit: No new updates at this time Facility shall submit by December 15, 2025 a detailed process for the emergency response system and procedures for staff. - LPA received documents on December 5, 2025 Facility shall provide monthly training to all facility staff on applicable Title 22 regulations Observation during today's visit: 11/27, 12/23, 01/15/2026the state’s words, verbatim · CDSS document, Jan 26, 2026

Allegation investigated: Staff did not ensure that resident was assisted with glucose testing

Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to deliver complaint investigation. LPA Valerio met with Administrator Ryan Nakao, and explained the purpose of the visit. The following has been determined as it relates to the allegation: Staff did not ensure that resident was assisted with glucose testing 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. Continueson LIC 9099 - C... Substantiated 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. 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... 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.the state’s words, verbatim · CDSS document, Jan 22, 2026 · control 27-AS-20250528153817

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jan 23, 2026

87465 Incidental Medical and Dental Care (a) ...(4) The licensee shall assist residents with self administered medications as needed. This requirement was not met as evidenced by: Based on records review of R1's EMAR, the licensee did not ensure R1's blood glucose level was checked by staff at 8:00 AM on April 26th and 27th of 2025, which poses an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 22, 2026

Plan of correction: Licensee stated the facility has hired a new Wellness Director (LVN) and has completed in-service training with past and current staff since May of 2025. LPA received copies of training. POC cleared during today's visit.

Allegation investigated: Staff does not ensure to follow proper food safety policies

Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct a complaint investigation and deliver findings. LPA Valerio met with Administrator Ryan Nakao, and explained the purpose of the visit. The following has been determined as it relates to the aforementioned allegation. On 12/31/2025, the Regional Office was notified that the facility allegedly does not follow proper food safety protocols by allowing diary products, such as creamer, and juice to sit out in the morning for hours at a time. It was alleged that the facility kitchen lead staff and management have known for years and do nothing about it. LPA Valerio was sent multiple pictures on 01/02/2026, 01/05/2026, and 01/06/2026. Continues on LIC 9099 - C... Unsubstantiated On January 2, 2025, a picture of a table with a set of dinning utensils, white coffee cup, and a small 2oz stainless steel container with creamer was sent to LPA Valerio. According to the RP, the picture was taken around 7:00 AM and breakfast did not start until 8:00 AM. On January 4, 2025, a picture was sent to LPA of a dining table with the table set (paper placemat, rolled up utensils, a white coffee cup, and two small 2 oz stainless steel cup filled with creamer). There was a large clock in the background, which showed the time of 7:05 AM. On January 5, 2025, a picture of 20+ unfilled glass cups and 1 glass cup filled with juice was sent to LPA. The juice was said to be prune juice, which was pre-poured before residents arrived for breakfast. The picture was sent to LPA at 8:56 AM; however, it was reported that it was taken around 7:00 AM. LPA Valerio conducted two unannounced visits on 01/06/2025 and 01/09/2025. On 01/06/2025, LPA Valerio observed lunch service. Drink products were observed to be on ice. The salad prep area was observed to be on ice. Staff were observed to be cleaning, serving residents, and wearing hair nets while in the kitchen. LPA Valerio observed food products to be of good quality and unexpired. LPA observed an adequate supply of perishable food items. LPA Valerio observed the kitchen to be clean. LPA Valerio observed kitchen staff to have up to date Food Handler certificates. On 01/09/2025, LPA Valerio observed breakfast service. LPA Valerio observed creamer and diary products to be on ice. LPA Valerio observed fruit and vegetables that were prepped for breakfast being put on ice. According to interviews conducted with staff, staff deny the allegations being true. Staff expressed following food safety protocols. It was reported that residents come down as early as 6:30 AM; however, breakfast service does not start until 7:30 AM. For the residents that come down early to wait, serving staff will provide coffee. According to interviews with residents, there were no concerns disclosed and expressed being happy with the food service. 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. An exit interview was held, and a copy of report was left at the facility.the state’s words, verbatim · CDSS document, Jan 9, 2026 · control 27-AS-20251231092021

Allegation investigated: Facility staff are not dispensing medication as prescribed

Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to deliver complaint investigation findings. LPA Valerio met with Licensee Brian Walgenbach, and explained the purpose of the visit. The following has been determined as it relates to the aforementioned allegation. Allegation: Facility staff are not dispensing medication as prescribed It was alleged that a facility staff member attempted to provide incorrect medications to a resident in care. The resident noticed the pills were incorrect and informed the staff member. The resident also stated their spouse's orders for diabetes and blood pressure are not followed correctly by staff. Continues on LIC 9099 - C... Substantiated 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. 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.the state’s words, verbatim · CDSS document, Jan 6, 2026 · control 27-AS-20250417091827

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jan 7, 2026

87465 Incidental Medical and Dental Care (a) ...(4)The licensee shall assist residents with self-administered medications as needed... This requirement was not met as evidenced by: Based on records review of R1, R2, and R3, staff did not complete the medication orders. This poses an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 6, 2026

Plan of correction: Licensee stated the facility has conducted medication training with the nurse consultant and hired a new nurse. LPA to receive copies of the training by the due date.

Allegation investigated: Facility does not ensure staff treat residents with respect. Facility does not ensure care is being provided when staff come in to “clear the call button.” Facility does not ensure staff are physically capable of performing their required job duties. Facility does not ensure that residents get their scheduled showers. Facility does not ensure that all staff respond to the call buttons in their assigned areas.

Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to deliver complaint investigation findings. LPA Valerio met with front desk staff and explained the purpose of the visit. LPA was later met by Licensee Brian Walgenbach. The following has been determined as it relates to the aforementioned allegations. Allegation: Facility does not ensure staff treat residents with respect According to the Reporting Party (RP), the facility staff had to participate in an in-service regarding how to treat and approach residents as some residents have been treated curtly. Continues on LIC 9099 - C... Unsubstantiated Based on interviews conducted with four (4) residents, the residents did not express that residents were not treated with respect. LPA Valerio reviewed facility files. There was a staff member (S1) that was talked to by management staff regarding the way S1 allegedly spoke to a resident. S1 denied the allegation. LPA Valerio attempted to interview S1 but did not receive a call back. Based on an interview with Administrator Ryan, they had a Resident Rights in-service Allegation: Facility does not ensure care is being provided when staff come in to “clear the call button.” According to the RP, there are staff, specifically staff 1 (S1) who refuse to respond to call lights. The RP also stated that staff who are not direct care staff will come in to clear the lights but do not provide actual care. RP reported that the RP's call light was not answered until an hour and forty minutes later because the staff who answered could not physically assist the resident. When staff were finally available, the staff members said they were busy and "it was no their hall". LPA Valerio reviewed facility files. Facility files revealed that S1 was written up on multiple occasions for call light response times longer than 15 minutes, S1 not helping other staff members, and S1 not answering call lights. LPA Valerio reviewed resident council meeting minutes. For the month of February, March, and April, Call lights were one of the many topics discussed. LPA Valerio read a note that stated, ""Staff clear what the executive director termed the "emergency" call button, but may then leave only to assist the resident at a later time. Ryan stated when answering calls, staff have to give emergency needs priority. Revaluating a resident's needs may indicate that instead of relying on the call button, setting a regular time for assistance may be more appropriate. According to staff interviews, all staff, including business office and front desk staff, have pages so they could respond to call alerts. According to Administrator Ryan, call lights can be answered by any staff member. If the staff member is not a direct care staff, they can determine if the resident is in an emergency situation or if the staff can assist the resident. For example if a resident needed the remote, any staff member can assist the resident. Allegation: Facility does not ensure staff are physically capable of performing their required job duties. According to the RP, the facility allowed Staff 2 (S2) to work when they could not physically do their job. According to the RP, the RP needed two persons to lift RP. However, S2 was unable to do such act and had to wait for two other staff members to assist the RP. LPA Valerio reviewed facility files. S2 was on schedule as a direct care staff while on a modified work status. Based on interviews conducted, S2 was to work within S2's capabilities. It was understood that S2 would assist staff on shift with their duties while the other staff assisted S2. LPA Valerio attempted to interview S2; however S2 did not return LPA's call. Allegation: Facility does not ensure that residents get their scheduled showers. According to an interviews with residents, 4 out of 5 residents did not disclose anything to support the allegation of resident not receiving their scheduled shower. According to one resident interview, the facility was so short staff, they did not get their shower on Monday and was told they would get their shower on Tuesday. That resident reported they did not get their shower until Saturday that week. LPA Valerio reviewed facility documentation. The facility has set shower schedule for each resident. Showers vary depending on each resident; however, showers were scheduled for every two to three days. The facility does not have a way to track whether a resident has gotten a shower or not. Allegation: Facility does not ensure that all staff respond to the call buttons in their assigned areas. LPA Valerio reviewed facility documentation. LPA Valerio reviewed one staff write up that was given on 02/25/25. The staff member was written up for not answering call lights and answering call lights after a long period of time. According to the staff, the staff member would "forget to clear the call button". Another write up shows that a staff was written up for responding to call lights after a 15 minute wait period. That staff stated they have been doing their best and all other staff were busy to help. Based on resident interviews, staff member have responded to their call lights. Based on all the information collected by the Department, although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the allegations occurred, therefore the allegations are UNSUBSTANTIATED. California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. An exit interview was held and a copy of report was left at the facility.the state’s words, verbatim · CDSS document, Jan 6, 2026 · control 27-AS-20250416141742

Allegation investigated: Questionable death. Staff yell at residents. Staff handle residents in an inappropriate manner. Staff are under the influence of drugs and alcohol while caring and supervising residents. Staff engage in sexual activities in the presence of residents. Staff do no answer resident's call buttons in a timely manner. Staff do not allow residents access to resident's call buttons

Licensing Program Analyst (LPA) Christina Valerio arrived to the facility to deliver complaint investigation findings. LPA Valerio met with Executive Director Ryan Nakao, and explained the purpose of the visit. The investigation was conducted by LPA Kimberly Viarella, LPA Vincent Moleski, LPA Christina Valerio, and Investigator A. Blatnick. The investigation consisted of resident interviews, staff interviews, and facility records review. The following has been determined as it relates to the aforementioned allegations. Allegation: Questionable Death / Staff handle residents in an inappropriate manner. According to an interview with the Reporting Party (RP), it was alleged that Resident 1 (R1) passed away after being handled roughly by a staff member, Staff 1 (S1). According to a review of the Regional office's facility records, a death report was submitted by the facility for Resident 1 (R1). Continues on LIC 9099 - C... Unsubstantiated According to the death report, R1 passed away on 01/12/2025, cause of death was "unspecified protein calories malnutrition with "DM2" as contributions contributing to death. R1 was 101 years of age and on hospice care. LPA Valerio reviewed shower screen logs, which is where staff also log/indicate any skin concerns such as tears, bruises, etc. LPA Valerio did not review any notes that indicated signs or observations of bruising by facility staff. On 12/24/2025, staff notes indicate resident refused a shower, indicated R1 was in pain, and that R1 stated R1 was going to pass and to call R1's son. LPA Valerio reviewed progress shift notes. There was only one note written before R1's passing , which indicated that on 01/02/2025, Alpha One was called due to R1 being unable to speak due to pain. The next note was written on 01/12/2025, which informs how staff found resident in bedroom without vital signs. LPA Valerio reviewed R1's facility file. LPA Valerio did not find any information to corroborate the statement that R1 passed away due to being mishandled by staff. Allegation: Staff yell at residents According to an interview with RP, RP heard from other staff that S1 was yelling at R1 and was later banned from assisting R1. According to an interview with Staff 2 (S2), R1 told S2 that staff were mean to R1; however, R1 would never disclose the names of the staff. S2 stated S2 was no aware of anyone yelling at residents, but knows that staff have yelled at S2 in front of residents. S2 stated staff would yell at S2 for asking for help. According to an interview with Resident 2 (R2), R2 initially stated that no staff have ever yelled at R2. R2 then recalled a time when S3 was close to R2's face speaking loudly. According to an interviews with Resident 3 (R3) - Resident 5 (R5), they did not disclose information regarding staff yelling at them. LPA Valerio attempted to interview S1; however, LPA never received a callback. S1 no longer works for Golden Pond Retirement Community. Allegation: Staff are under the influence of drugs and alcohol while caring and supervising residents. It was alleged that S1 had been under the influence of alcohol and drugs while caring for and supervising residents. According to an interview with S1, S1 denied drinking alcohol at the facility and denied snorting a white substance at the facility. S1 admitted speaking to S4 for being hung-over at work. According to an interview with S3, there was a staff member who was written up in 2022 for drinking at the facility. That staff member was found to have multiple empty bottles of alcohol in their locker. That staff member was terminated in 2025 for attendance issues. S3 reported that it was relayed to S3 that another staff member was smoking marijuana in the back of the facility and received disciplinary action. According to an interview with Staff 7 (S7), S7 has seen many staff "under the influence" many times. S7 has seen S1 come to work hung-over and smelling like alcohol. S7 denied ever seeing S1 snorting a white substance while at work. Allegation: Staff engage in sexual activities in the presence of residents. It was alleged that Staff 5 (S5) and Staff 6 (S6) were caught engaging in sexual activities in a resident's room. LPA Moleski sought clarification on the specific incident. It was confirmed that the incident that took place described by RP took place in the facility parking lot, not a resident's room. According to an interviews conducted with facility staff, staff only heard rumors of staff engaging in activities. For example, S2 reported that S2 heard two staff were taking a resident out to the patio and then were seen kissing in front of the resident. S2 does not know the names of the staff or resident. S5 denies ever engaging in sexual activities during work. LPA attempted to interview S6; however, the interview was unsuccessful. Allegation: Staff do no answer resident's call buttons in a timely manner. According to an interview with the RP, R1 waited over an hour for R1's call light to be answered. R1 could not be interviewed due to R1 passing away. According to an interview with R2, R2 stated staff take a while to respond to call lights and feel the facility is short staff. R2 states that it could take up to 15 minutes for staff to respond to a call light. R2 believes 15 minutes is too long. If there were an emergency, 15 minutes would be too late. According to an interview with R3, R3 believes the facility is understaffed. R3 stated facility staff respond within “five minutes to an hour and a half.”R3 said the reasoning for late response times are “they always say that someone has fallen, and they were helping them.”R3 does not know how many times facility staff took an hour and a half to respond. According to an interview with R4, R4 does not believe the facility to be understaffed. R4 presses the pendant and staff respond within minutes. R4 suffered a fall and pressed the pendent. Staff were there immediately after. According to an interview with R5, R5 stated facility staff respond within “ten minutes" and “sometimes” facility staff can be slow to respond to [R5] but for the “most part,” the facility staff respond quickly. LPA Valerio reviewed facility call light records. LPA Valerio reviewed 51 pages of call light responses. LPA Valerio found 11 call lights that were answered over 15 minutes long. Times varied between 16 minutes up until 7 hours and 53 minutes. According to an interview with S3, S3 stated that sometimes staff forget to clear the call light, which would explain anything over an hour. S3 stated the facility always encourage staff to respond right away. According to an interview with S2, S2 stated staff would get in trouble if they responded to a call light late. S2 stated S2 tried their best to get to all the call lights, but ,sometimes, would be the only person for the entire floor. According to Administrator Ryan, the call lights that showed the note "supervision expired" is not the call light response time, and actually is the battery for the door or unit saying it needs to be change or changed soon. LPA Valerio confirmed the note for the 7 hours and 53 minutes call light had the note "supervision expired". Allegation: Staff do not allow residents access to resident's call buttons. It was alleged that facility staff hide the resident's call button so that residents cannot press the button. According to the RP, the RP saw R1's pendant sitting across the room. R1 would not be able to move the pendant because R1 was on hospice. According to an interview with S2, S2 stated S2 knows forsure that staff would hide pendants, especially for Resident 6 (R6). R6 was known to press the call button frequently and staff hid it so R6 would not press it. S2 stated S2 never hid it, but knew of staff who did. S2 does not know the names of the staff. S2 stated when S2 worked with R1, R1 always had R1's pendant around the neck. LPA Valerio could not interview R6 due to R6 passing away. R1 could not be interviewed due to passing away. According to an interview with R2, R2 has never had their pendant hidden from them. According to an interview with R4, R4's pendant is located around R4's neck and can easily press it for assistance. According to R5, R5's pendant is located around the neck and has not been hidden by staff. Based on all the information collected by the Department, although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the allegations occurred, therefore the allegations are UNSUBSTANTIATED. California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. An exit interview was held and a copy of report was left at the facility with Administrator Ryan Nakao.the state’s words, verbatim · CDSS document, Dec 15, 2025 · control 27-AS-20250213140526

Type of visit: Office

On December 03, 2025, a virtual office meeting was held via Microsoft Teams to discuss the Stipulation and Waiver. Present in today's meeting are the following: Community Care Licensing Representatives; Regional Manager (RM) Stephenie Doub, Licensing Program Manager (LPM) Stephen Richardson, Licensing Program Analyst (LPA) Christina Valerio and Facility Licensee representatives; Counsel of Payam A. Saljoughian of Hanson Bridgett LLP, Executive Director Ryan Nakao, and Licensee Brian Walgenbach. The purpose of this office meeting was to go over the Stipulation and Waiver for this facility and the Decision and Order that went into effect on 11/14/2025. All of the sections were reviewed with all of the above participants along with all applicable Title 22 Rules and Regulations, Health and Safety Codes, and Government Codes. Items discussed at the meeting included, but not limited to: Findings Revocation: Stayed with Probation - three (3) years Appeal of $15,000 Civil Penalty Denied Future Application for Licensure, Registration, Certification or Approval Tolling of Probationary Period Completion of Probation Violation of Stipulation Term Department's Authority Continues on LIC 809- C... Continued from LIC 809 Monitoring Fee Waiver of Hearing Rights Waiver of Appeal/Modification Rights Waiver of Claims Severable Terms Public Records Signatures Counterparts Effective Date No Oral Modification The licensee shall do the following: Facility shall operate in strict compliance with regulations and statutes... Facility shall ensure the facility is clean, safe, sanitary, and in good repair at all times Facility shall post the Stipulation in a conspicuous place at the facility Facility shall report any unusual incident... reported by the next working day and a written report within seven (7) days Facility shall maintain current personnel records of each employee Facility shall submit by December 15, 2025 a detailed procedure for maintaining records to ensure staff have current POLST/DNR orders Facility shall submit by December 15, 2025 the "no smoking:" policy reflected in the plan of operation and admission agreement or addendum thereto... Facility shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items... are in locked storage and are not left unattended Facility shall notify CCL when residents are given access to items.. and provide plan to ensure resident's or other residents' safety Facility shall reassess residents who are given access on a bi-annual basis Facility shall submit by December 15, 2025 a detailed process for the emergency response system and procedures for staff. Facility shall provide monthly training to all facility staff on applicable Title 22 regulations Community Care Licensing will do the following: Increase facility monitoring to quarterly visits during the probationary period Continue to maintain open communication lines with facility There were no deficiencies observed or cited at this time. An exit interview was held via cell phone to go over the contents of this report. A scanned copy of this report will be emailed to the facility Executive Director Ryan Nakao, who will sign and send back the signed copy to this LPA.the state’s words, verbatim · CDSS document, Dec 3, 2025

Allegation investigated: Insufficient staff

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with facility administrator Ryan Nakao and explained the purpose of the visit. This investigation consisted of interviews, observation, and record review. LPA Moleski interviewed Nakao, seven staff members (S1-S3, S5-S8), five residents (R1-R3, R6, R8). LPA Moleski also received a written statement from one resident’s responsible party (R4’s RP). LPA Moleski reviewed approximately seven months’ (April-Oct.) worth of medication administration records (MARs) for six residents (R3-R8) and reviewed approximately seven months’ worth of incident reports from this facility (May-Nov.). In an interview in May, Nakao said that cuts to staffing had recently been made because the facility had been over-staffed for some time. [continued on 9099-C] Substantiated 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] 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. 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] 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 discontinued, but merely out of refills. Starting on June 1, administration signatures indicate that R7 was again receiving their antimetabolite medication, although two missing signatures during the month of June suggest missed doses. Additional notes on June 8 and June 16 indicate that staff were once again waiting for the pharmacy to fill and deliver the same medication. Again, it is unclear whether or not R7 was receiving medication between these two dates, as medication technicians continued to sign for administrations, despite the notes indicating there was no medication in stock to provide to the resident. R8’s MARs show multiple missed signatures for multiple different kinds of medications given at different times of day on June 7-9, including their muscle relaxant, their stool softener, their immunosuppressant, their blood thinner, their anticonvulsant, their antidepressant, their painkillers, and more. On May 18, signatures were missing for midday and evening doses of several medications, including some of the above medications. Between September 4 and September 8, multiple signatures were missing for R8’s painkillers. In an interview, R8 said that the facility is understaffed, leading to long response times and medication administration issues. R8 said there have been several times wherein they have not received their painkillers at all, and other times wherein they do not get their medications on time. 22 CCR Section 87411(a) requires that “Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.” This section furthermore empowers CCLD to “require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents [or] the extent of services provided … require such additional staff for the provision of adequate services.” [continued on 9099-C] After LPA Moleski read over this report, Nakao said that the issues documented in this report were due to the lack of a nurse in the building, as their previous nurse had gone on extended leave, resulting in medication oversight issues. Nakao said that since hiring a new nurse in July, improvements have been made. The department has determined the following as it relates to the allegation that there is insufficient staff at the facility: Based on interviews and record review, 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 hereby cited per 22 CCR Section 87411(a). An exit interview was held with Nakao. Appeal rights and a copy of this report were left with Nakao.the state’s words, verbatim · CDSS document, Nov 21, 2025 · control 27-AS-20250501162842

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Nov 25, 2025

87411(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.” This requirement was not met as evidenced by: Based on interviews and record review, there have not been sufficient numbers of staff at this facility to complete all services necessary to meet resident needs, resulting in an immediate health, safety, and/or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Nov 21, 2025

Plan of correction: Licensee contends that corrections have already been made to address the primary issues documented in this report. Licensee agrees to provide LPA Moleski with a written statement identifying what corrections have been made. CCLD may require additional documentation to verify corrections at a later date. Athough this deficiency requires immediate correction, Nakao requested an extension due to the weekend. LPA Moleski granted that extension. vincent.moleski@dss.ca.gov

Allegation investigated: Facility staff did not do proper reappraisal on resident. Facility staff did not meet resident hygiene needs. Facility staff did not notify resident's responsible party of change in condition. Facility not releasing information about resident that has been requested by responsible party. Facility staff did not seek medical attention in a timely manner.

On 10/14/25, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to deliver the findings for this complaint investigation. 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. Through a record review, this LPA learned that on 12/17/24, the Medical Power of Attorney (POA) for resident (R1) indicated concerns to the Director of Care (DC) regarding a decline in R1 over the past month. A care conference was scheduled for 12/19/24. On that day, the POA met with the DC and shared their concerns. The POA stated that they, along with a family member (F) and another community resource member (CM), who visited the facility weekly, had noticed the following in the past month: strong urine smell on R1 and in their apartment, R1 not caring for themself, not changing clothes, not regularly bathing based on dry skin, smell, and appearance. The POA went on to mention R1 being unstable on their feet and that the POA had been trying to shift R1 from using a cane to using walker. Substantiated 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. 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. 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. 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. 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 POA on 02/01/25 however, no documentation was provided in response to the POA's email request on 02/21/25 regarding their change of care during the 30-day evaluation with regard to showers or assistance with other activities of daily living. The POA had the right to see the documentation regarding any care being provided to R1. According to CCR, Resident Records, 87506(c)(1) (c) All information and records obtained from or regarding residents shall be confidential. (1) The licensee shall be responsible for storing active and inactive records and for safeguarding the confidentiality of their contents. The licensee and all employees shall reveal or make available confidential information only upon the resident's written consent or that of his designated representative. Regarding: Facility staff did not seek medical attention in a timely manner. Based on interviews and a review of documents, a member of the kitchen staff was the first to find R1 "on the floor of their room in a puddle of urine" on 1/19/25 and they contacted a caregiver, who in turn contacted a medication technician to come and assess R1. According to CCR Incidental and Medical Care, 87465, " (g) Under #12 Toileting, it stated that, "Resident will maintain and/or maximize current level of functioning with toileting. Requires reminders or minimal use of bedside commode/urinal." During the care conference on 12/19/24, the DC learned that R1 smelled like urine and through interviews this LPA learned that R1 was having "accidents" in public areas. The care plan should have been updated to include a managed incontinence care plan. On page 4, under #14, Special Care, it stated, "Resident will maintain and/or maximize current level of functionality with special care needs. Fall concern." and then "None" was listed. No strategies were listed for addressing fall concerns based on the 3 recorded falls. Regarding: Facility staff did not do proper reappraisal on resident. Based on a review of records and interviews, the facility did not do a proper reappraisal of the resident. The Department finds the above allegation to be substantiated. This deficiency may be found on the LIC 9099D page. Regarding: Facility staff did not meet resident hygiene needs. This LPA requested the shower logs for R1. The facility provided 1 for 12/25/24 where they checked off that R1 refused a shower and another for 12/28/24 which had a handwritten note that stated "R1 said they already showered this morning." Skin checks were not done on either day and no concerns were noted. Under #9, on page 3 of R1's Service Plan, it stated that "Resident will maintain and/or maximize current level of functioning with bathing; prefers showers. R1 requires standby assistance, 2X per week for bathing. Shower days will be Tuesday and Wednesday." Documentation was not provided that showers were given or refused on R1's scheduled shower days: 12/17/24, 12/18/24, 12/24/24, 12/31/24, 01/01/25, 01/07/25, 01/08/25, 01/14/25, and 01/15/25. According to CCR Basic Services, 87464, it states, "(f) Basic services shall at a minimum include: (4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications…" Based on a review of these documents, the department found the above allegation to be substantiated. This deficiency may be found on the LIC 9099D page.the state’s words, verbatim · CDSS document, Oct 14, 2025 · control 27-AS-20250131102041

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87463(a) · Plan of correction due date: Oct 15, 2025

Reappraisals 87463 (a) The pre-admission appraisal...shall be updated in writing as frequently as necessary or once every 12 months.... The Licensee did not met the above requirement as evidenced by: Based on file review and interviews R1's last LIC 602 on file was 4/12/18. R1 had 3 documented falls and required more assistance with ADLs. A new appraisal and care plan were not updated to reflect the needed change in care, this posed an immediate risk to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Oct 14, 2025

Plan of correction: The ED stated that since the LPA brought this concern to their attention back in July of 2025 they have reached out to all resident physicians to obtain updated LIC 602's and the DC in conjunction with an outside consultant are reviewing and ensuring that all updated care plans are appropriate. This process is ongoing, and the ED will send CCL a written update with how many LIC 602s and care plans still need to be updated by the close of business tomorrow, 10/15/25.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(4) · Plan of correction due date: Oct 15, 2025

Basic Services 87464 (f) Basic services... include: (4) Personal assistance and care as needed by the resident and as indicated... The Licensee did not meet the above requirement as evidenced by: Based on a review of shower logs, R1 did was not given showers on 9 of their scheduled days & there was no docu- mentation to show that R1 refused. When sent to the hospital, a bleeding cancerous legion was found on R1's shoulder. This posed an immediate threat to the health...the state’s words, verbatim · CDSS document, Oct 14, 2025

Plan of correction: The ED stated that he will meet with his management staff to create an improved system to conduct and track resident showers. This will be submitted to CCL at CCLASCPSacramentoRO@dss.ca.gov by the close of business tomorrow, 10/15/25

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(7) · Plan of correction due date: Oct 15, 2025

Additional Personal Rights of Residents in Privately Operated Facilities 87468.2 (a) In addition to... the elderly shall have...(7) To fully participate in planning their care... The licensee shall provide necessary information... The Licensee did not meet the above requirement as evidenced by: Based on interviews with CR, S1, S3, and S8, a change in condition was observed priot to the POA bringing it to the DC's, ED's or Wellness Director's attention. It was not communicated to the POA. This posed an immediate threat to the health, safety, and personal rights of residents in care.the state’s words, verbatim · CDSS document, Oct 14, 2025

Plan of correction: ED stated that they will create a communication binder that will be kept in the crossover room that care staff have access to and it will be reviewed by the DC daily. The ED will send a picture of this binder to CCL by the close of business on 10/14/25 at CCLASCPSacramentoRO@dss.ca.gov.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(c)(1) · Plan of correction due date: Oct 17, 2025

Resident Records(c) All info shall be confidential. (1) The licensee...The licensee and all employees shall reveal or make available confidential information... his designated representative. The Licensee did not meet the above requirement as evidenced by: Based on a review of emails supplied by both the ED and the POA, the requested incident reports were not supplied in a timely manner and the written details for the change in care plan were never supplied to the POA. This posed a potential threat to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Oct 14, 2025

Plan of correction: The ED stated that he will review and education the department heads on the this regulation to ensure that all requests for documentation are met in a timely manner. This training will be completed by 10/17/25 and the ED will send a signature sheet of partipcants to CCL at CCLASCPSacramentoRO@dss.ca.gov.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: Oct 15, 2025

Incidental Medical and Dental Care 87465(g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat... The Licensee did not ensure the above requirement was met as evidenced by: Based on interviews with 3 staff members, the first person who found R1 on the floor in a puddle of urine should have contacted 911. This delay in medical assistance posed an immediate threat to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Oct 14, 2025

Plan of correction: ED stated he will condcut a training to review emergency procedures and this regulation with all staff. ED to condcut all staff on 10/16/25. He will submit an agend to CCL at CCLASCPSacramentoRO@dss.ca.gov by the close of business tomorrow, 10/16/25 and a signature sheet of attendees on 10/17/25

Type of visit: Case Management - Deficiencies

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. 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 state’s words, verbatim · CDSS document, Oct 14, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Oct 15, 2025

Observation of the Resident 87466 The licensee shall ensure... regularly observed for changes in physical, mental, emotional and social functioning... changes are documented... The Licensee did not ensure the above requirement was met as evidenced by: Based on document review, 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. This posed an potential threat to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Oct 14, 2025

Plan of correction: ED stated that they will create a communication binder that will be kept in the crossover room that care staff have access to and it will be reviewed by the DC daily. The ED will send a picture of this binder to CCL by the close of business on 10/14/25 at CCLASCPSacramentoRO@dss.ca.gov.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(6) · Plan of correction due date: Oct 15, 2025

Incidental and Medical and Dental Care CCR 87465(h)(6) Staff responsible for assisting residents with self admin. of meds shall receive training as specified in...before they assist residents with medications. The Licensee did not me the above requirement as evidenced by: Based on a review of the EMAR for Sunday 9/21/25, the Executive Director, who has not had medication technician training, was administering medications in memory care. This posed an immediate risk to the health, safety and personal rights or residents in care.the state’s words, verbatim · CDSS document, Oct 14, 2025

Plan of correction: ED to start Medication Technician trainining tomorrow on 10/15/25 and will send a copy of their progress sheet by the close of business tomorrow 10/15/25 to: CCLASCPSacramerntoRO@dss.ca.gov.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87411(a) · Plan of correction due date: Oct 15, 2025

Personnel 87411 (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... The Licensee did not ensure the above requirement was met as evidenced by: Based on a document review staff (S13) did not conduct 2 hr checks on R1, their initials were on the checklist for NOC shift on 1/18/25, but R1 would not have been on the floor in their daytime clothes and soaked in urine if the checks had been done. This posed an immediate threat to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Oct 14, 2025

Plan of correction: Director of Care will review cross-over sign-off sheets daily to ensure all tasks have been completed. ED and DC will create a cross-over sign-off sheet that will be submitted by the close of business tomorrow to CCLASCPSacramerntoRO@dss.ca.gov.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87207 · Plan of correction due date: Oct 14, 2025

False Claims 87207 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. The Licensee did not ensure that the above requirement was met as evidenced by: LPA received a copy of a statement that documented observations from that morning when R1 was found. This posed an potential threat to the health, safety and personal rights or residents in care.the state’s words, verbatim · CDSS document, Oct 14, 2025

Plan of correction: ED stated that they will create a communication binder that will be kept in the crossover room that care staff have access to and it will be reviewed by the DC daily. The ED will send a picture of this binder to CCL by the close of business on 10/14/25 at CCLASCPSacramentoRO@dss.ca.gov.

Allegation investigated: Licensee is not ensuring the resident's room is kept at a comfortable temperature.

On 09/03/25, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to open an investigation into the above allegation. LPA identified herself upon arrival, stated the purpose of the visit, and asked to meet with the Designated Facility Administrator/Executive Director. LPA met with Ryan Nakao and a brief interview followed. Regarding the above allegation, on Saturday 08/30/25, the responsible party of resident (R1) was contacted by the private caregiver for R1 that the air conditioning (AC) in R1's room was not working and it was very hot. According to the Weather Channel, the outisde temperature in Sacramento that day was 102 degrees Fahrenheit. The RP called the front desk but could not contact anyone to assist. The private caregiver spoke with facility staff who notified maintenance about the problem. Maintenance staff (M1) responded to assess the situation. M1 could not fix the problem and contacted their supervisor (M2). M2 contacted the Executive Director and was given permission to relocate the resident to another room while they contacted the appropriate person to repair the air condioning in the resident's room. A repair person arrived that same day Unsubstantiated and determined that the system needed a part that could not be ordered until Monday, but they would do so and return as soon as they received it on Tuesday, 09/02/25 or Wednesday, 09/03/25. RP was offered the option of moving R1, they declined. In an interview with RP, they explained that R1 required certain adaptive medical furniture and since no one offered to move any of R1's furniture or belongings, they did not feel that R1 would be comfortable or able to function well in the other room. In interviews with M2 and the Executive Director, both stated that they offered to move R1's belongings, and that RP declined. On Saturday, after declining to move, maintenance brought in a portable AC unit. During today's walkthrough, this LPA observed the portable AC unit in R1's room. It was not installed in a window or patio door opening. It was missing the flex tubing that is supposed to pull air from the outside. It was located just inside the apartment door and venting into the hallway. During my visit it was off, however in an interview with the RP, this LPA learned that when it was first brought in it was put near the open patio slider. It would blow cold air toward one area, however it was venting hot air into the rest of the apartment. As it was not installed in the slider, there was additional hot air coming into the room from that door-sized opening. This did not provide any consistent or comfortable temperature. The RP stated that it got too cold and that was why the unit was relocated to the doorway. M2 provided this LPA with time stamped photos of temperature readings taken with the same type of thermometer that LPAs use in facilities. He recorded the following: 8/31/25 at 4:12 PM in the living room, and approximately 2 -3 feet away from the AC unit the temperature was 68 degrees Fahrenheit. At 4:13 PM the temperature in the bedroom measured 76 degrees Fahrenheit, by the television, it measured 70 degrees Fahrenheit. M2 and the RP had a conversation about R1's preferred temperature and on Tuesday 09/02/25, the temperature measured 76 degrees Fahrenheit in the bedroom. M2 also showed the private caregiver how to adjust the temperature on the portable AC unit so that the resident could increase or decrease it for their comfort. The RP stated that on Tuesday at 10:58 AM the Executive Director (ED) offered to move R1 to the memory unit. The RP stated that R1 would need all of their adaptive equipment and they did not want R1 in the memory unit. The ED then offered to move R1 and their adaptive furniture to an empty room. At this point, the RP visited the facility and the room was 78 degrees and they were told that a repair person was coming within the next day or two. R1 was on hospice and the RP did not want to disrupt their life and belongings unless it was absolutely necessary. Through interviews with M1 and M2, this LPA learned that repair people had been contacted, that one had come out to the facility and determined that there was a part they needed that could be ordered on Monday, 09/01/25 and the system was repaired earlier today on 9/3/25. The facility did try to fix the issue with the air-conditioner when they first learned of it. They also offered to move the resident to a new room. They contacted a repair person and scheduled a maintenance visit. However, when they could not fix the AC right away and the resident did not wish to move to a new room, they brought in a portable air conditioner that did cool the room. The temperature was not consistent throughout the apartment, but the option to relocate to another room was provided. The standard for the preponderance of evidence was not met and therefore the Department found the above allegation to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. 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 was provided along with APPEAL RIGHTS. Exit interview.the state’s words, verbatim · CDSS document, Sep 3, 2025 · control 27-AS-20250903122428

Allegation investigated: Facility water supply is contaminated Staff did not follow resident POLST order

Licensing Program Analysts (LPAs) Vincent Moleski and Triel Lindstrom arrived unannounced to follow up on this complaint investigation. LPAs Moleski and Lindstrom met with facility administrator Ryan Nakao and explained the purpose of the visit. LPA Moleski was not able to contact the initial complainant who made these allegations for explanation. LPA Moleski interviewed multiple staff members, and the only instance any staff were aware of regarding a POLST order which was not followed occurred in September 2023. The Community Care Licensing Division (CCLD) followed up on this incident and issued a Type A citation on 9/26/2023. LPA Moleski reviewed incident reports sent from this facility and did not observe any recent situations wherein this may have occurred. [continued on 9099-C] Unsubstantiated 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. 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.the state’s words, verbatim · CDSS document, Aug 25, 2025 · control 27-AS-20250501162842

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Aug 26, 2025

"(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: ... (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment." This requirement was not met as evidenced by: Based on interviews, residents were not accorded comfortable accommodations on at least one occasion, which poses an immediate health, safety, and/or personal rights risk.the state’s words, verbatim · CDSS document, Aug 25, 2025

Plan of correction: Licensee adressed personal rights during a prior all-staff meeting and agreed to provide LPA Moleski with notes from this meeting. vincent.moleski@dss.ca.gov

Allegation investigated: Facility staff acting unprofessionally in front of residents.

On 07/29/25, Licensinng Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to deliver the findings for the investigation into the above allegation. LPA idenitified herself upon arrival, stated the purpose of the visit, and asked ot meet with the Designated Faciltiy Administrator/Executive Director (ED), Ryan Nakao. The two met and a brief interview followed. Regarding the allegation: "Facility staff acting unprofessionally in front of residents." There was an incident that took place on or about the first week of June in 2024, when a caregiver experienced a medical issue and was found unconscious and unresponsive on the floor. Staff on duty began calling the Director of Care (DC) whose shift had ended and was gone for the day. According to interviews with the DC and R1, multiple staff members called the the DC, but were not connecting. When the DC answered the phone, they were unaware the phone was on speaker. The DC answered the phone using expletives and asking why staff were calling. According to a document review, "staff were demanding that Unsubstantiated the DC come in and the DC used more expletives and told them to utilize the medication technicians." In an interview with this LPA, the DC stated that they had worked a double shift and had gone to bed. When the staff called, they were sleeping and exhausted. The DC went on to state they realized they should not have responded the way they did. "I own my mistakes and I have learned from them." On 06/07/24, the DC went to the ED and shared that they had spoken inappropriately with their staff when they called the DC at around 11:00PM. That conversation was documented in a letter the ED provided this LPA. The document was dated 06/18/2024 and it recorded that conversation and also stated that the DC was counseled on proper communication and the need to be an example to the staff. It went on state that the ED would meet with the DC for the next 6 weeks beginning on 06/21/24 to discuss how "they were managing expectations and how they were strategizing ways to communicate properly." The DC successfully completed this process. Due to the fact that this event happened around 11:00 PM when most residents were in their rooms and/or sleeping, this LPA could not locate any residents who witnessed this event. The standard for the preponderance of evidence has not been met and the allegation "Facility staff acting unprofessionally in front of residents." was found UNSUBSTANTIATED. A finding of unsubstantiated does not mean that the event did not happen or was not true, it means that there was not a preponderance of evidence to prove that the allegation occurred. 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 was provided along with APPEAL RIGHTS. Exit interview.the state’s words, verbatim · CDSS document, Jul 29, 2025 · control 27-AS-20250130163859

Allegation investigated: Staff are not being properly trained.

This report was amended to reflect that it was delivered on 07/15/25 when Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to deliver the findings of this complaint investigation into the above allegation. 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. Regarding: Staff are not being properly trained. LPA reviewed the personnel files to ensure that the initial and annual trainings were up to date for all the medication technicians at the time of this complaint. LPA found that in 4 out of 4 staff files reviewed, (S2, S6, S5, and S19) none of the staff had the required documentation to ensure that all of the training required under the California Code of Regulations, Title 22 had been completed. Under Health and Safety Code 1569.69(a)(1), "In facilities licensed to provide care for 16 or more persons, the employees shall complete 24 hours of initial training. This training shall consist of 16 hours of hands-on shadowing, which shall be Substantiated 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 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." 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. 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.the state’s words, verbatim · CDSS document, Jul 15, 2025 · control 27-AS-20250122143006

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jul 16, 2025

(4) The licensee shall assist residents with self administered medications as needed." This requirement was not met as evidenced by: Based on interviews and a review of records, S19 gave the wrong medication to two different residents on 2 different occasions. This posed/poses an immediate threat to the health safety and /or personal rights of the residents in care.the state’s words, verbatim · CDSS document, Jul 15, 2025

Plan of correction: The Executive Director(ED) stated that the employee who made the errors was terminated. The ED stated that they have just hired a new Wellness Director and together they will be utilizing the training log provided by the technical support program to ensure that all required is The ED stated he will submit and outline the hours allocated for each training topic to this LPA by the close of business on 07/16/25 and submitted to kimberly.viarella@dss.ca.gov

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.69(a) · Plan of correction due date: Sep 1, 2025

Employees assisting with sellf-admini- stration of medication; training require- ments (a)...shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements... This requirement was not met as evidenced by: In 4/4 files reviewed, this LPA observed that training did not meet the requirements mandated. This poses/posed a potential risk to the health, safety and personal rights of the residents in care.the state’s words, verbatim · CDSS document, Jul 15, 2025

Plan of correction: The ED stated that they have just hired a new Wellness Director and togehter they will be utilizing the training log provided by the technical support program to ensure that all required is completed and by the close of business by 09/01/25 and submitted to Community Care Licensing at CCLASCPSacramentoRO@dss.ca.gov

Type of visit: Case Management - Deficiencies

On 07/15/25, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to conduct a case management visit following the delivery of findings for a complaint investigation. 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. During her walkthrough, LPA observed 3 caregivers, 2 housekeepers, and 2 staff delivering laundry. There were also a crew of workman installing new flooring and carpeting on the first floor and one of the stairwells. On the second floor, LPA observed 7 residents in the Pub enjoying beverages and singing along with a musician/entertainer. The Activities Director was tending bar and singing along. After the tour LPA and ED sat down to discuss the items in this case management. During the previous complaint investigation (#27-AS-20250122143006) LPA observed additional Title 22 violations. Per California Code of Regulations 87412(c)(2), the required mandated documentation regarding training was incomplete in 4 out of 4 files reviewed. Per CCR 87411(c)(1), "Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross." At the present time, the staff are not being trained from qualified persons such as the American Red Cross. These deficiencies have been cited on the LIC 809D Page. LPA had questions regarding agency staff not being cleared in Guardian, however due to time constraints and the fact that agency staff is not currently scheduled, this LPA will follow up at a later date. 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.the state’s words, verbatim · CDSS document, Jul 15, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87412(c)(2) · Plan of correction due date: Sep 1, 2025

Personnel Records 87412 Licensees shall maintain in the personnel records verification of required staff training and orientation. (2) Documentation of staff training shall include... This requirement was not met as evidenced by: LPA reviewed 4/4 files and none contained all of the required documentation showing that mandated training had been completed. This poses/posed a potential threat to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Jul 15, 2025

Plan of correction: Executive Director (ED) stated they will be utilizing the Log provided by the Technical Support Program and will consult with TSP regarding the required documentation for the hands-on component. ED will sent a sample of 6 updated training logs by the close of business on 09/01/25.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87411(c)(1) · Plan of correction due date: Sep 1, 2025

CCR 87411 (c) All RCFE staff...(1)Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement was not met as evidenced by: None of the 4/4 files reviewed contained documentation regarding first aid or CPR training from a vendor like the American Red Cross as required. This poses/posed a potential threat to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Jul 15, 2025

Plan of correction: ED has reached out to multiple companies to secure a qualified training in August, 2025, ED provide LPA signatures sheets for those who participated by the close of business on 09/01/25 to this LPA at kimberly.viarella@dss.ca.gov.

Allegation investigated: Facility staff are not conducting proper assessments.

On 05/01/25, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to deliver the findings of this complaint investigation. LPA identified herself upon arrival, state 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. Regarding the allegation: Facility staff are not conducting proper assessments. During this investigation, this LPA requested a sample of resident files including their pre-appraisals, any re-appraisals and care plans. This LPA learned that there was an assessment tool (Yardi) that was supposed to be utilized to determine each resident's care plan, including fall risk. This LPA also learned during interviews and a review of records that this tool was not consistently or properly used by S7. Upon reviewing the file for resident 5 (R5), LPA observed that the resident's pre-appraisal (dated 3/29/22) was completed after the admissions agreement was signed (3/28/22) and the file did not contain Substantiated 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 "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. 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.the state’s words, verbatim · CDSS document, May 1, 2025 · control 27-AS-20240815141325

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87459(a) · Plan of correction due date: Jun 30, 2025

87459 (a) The facility shall assess the person's need for personal assistance and care by determining his/her ability to perform specified activities of daily living... Such activities shall include, but not be limited to: (1) Bathing, including need for assistance: (D) Walking with or without equipment or other assistance. (E) Dietary limitations. (F) Medical history and problems. (G) Need for prescribed medications. The facility did not ensure the above regulation was met as evidenced by: Based on a review of records, in 3 cases, evaluation/appraisals for 3 residents were not incomplte, contained contradictory information, or not completed in a timely manner. This posed/poses a potential threat to the health, safety and/or personal rights of residents in care.the state’s words, verbatim · CDSS document, May 1, 2025

Plan of correction: The Administrator stated that the Memory Care Coordinator and the Care Coordinator completed Yardi training to improve their understanding of how to utilize and implement this tool properly. This was completed April 2025. The facility also stated that they will audit their resident files to ensure that their accurate and current and that they identity how to meet the needs of their residents.

Type of visit: Case Management - Deficiencies

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.the state’s words, verbatim · CDSS document, Feb 14, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(A) · Plan of correction due date: Feb 18, 2025

...(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of ... Death of any resident from any cause ..." This requirement was not met as evidenced by: Based on record review and interview, a death report was not submitted to CCLD as required per 22 CCR, which poses a potential health, safety, and/or personal rights risk.the state’s words, verbatim · CDSS document, Feb 14, 2025

Plan of correction: Licensee agrees to provide LPA Moleski a written plan to prevent future reporting errors. vincent.moleski@dss.ca.gov

Type of visit: Case Management - Annual Continuation

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 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.the state’s words, verbatim · CDSS document, Jan 29, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(4) · Plan of correction due date: Feb 26, 2025

Basic Services (f) Basic services shall at a minimum include: (4) Personal assistance and care as needed...with those activities of daily living.... The Licensee did not ensure the above as evidenced by: The LPA and the Marketing Director waited 20 minutes for assistance after activating the alert system in a memort care resident's room. Care staff never responded. This posed a potential threat to the health, safety, and personal rights of residents in care.the state’s words, verbatim · CDSS document, Jan 29, 2025

Plan of correction: The Executive Director stated that 8 pagers were being ordered so that all Care Staff and Managers would carry one. And Alert Logs will be reviewed by Care Director 2X a week and the Executive Director and additional 2X a week for 4 weeks and then reassess if still needed. A report of the results will be emailed to community care licensing and this LPA at cclascp@dss.ca.gov; kimberly.viarella@dss.ca.gov by 2/26/25

Type of visit: Required - 1 Year

Unannounced Annual Inspection visit was made by Licensing Program Analyst (LPA) Kimberly Viarella to this facility on 1/28/25. 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. The tour began in the kitchen. LPA inspected pantry area and pulled sample of a dozen dry goods to ensure that all were dated and stored properly. LPA then inspected the walk-in refrigerator and freezer. All food items were dated and packaged properly at the time of this inspection. The hood over the primary stove was last inspected on 11/07/24 by Niagara Hood Cleaning and it was in compliance at the time of this inspection. LPA also observed that fire extinguishers were last inspected on 8/30/2024 by Foothill Fire Ins. and were also in compliance. LPA observed food supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. LPA, escorted by the Marketing Director, entered a resident’s room in memory care, as the door had been left open. LPA pulled the emergency cord in the bathroom to test response time. After 20 minutes, the LPA and the Marketing Director left the room to alert the Memory Care Director to the fact that they had gotten no response. LPA located the Memory Care Director (MCD) along with 2 care staff assisting 8 of the 12 residents in memory care with lunch. LPA informed the MCD and the ED about the lack of response to the alert activated. LPA inspected 2 resident rooms memory care. Each had the required furniture, furnishings, and lighting to be in compliance. Bathrooms had grab papers, towels, and non-skid surfaces in the showers. Hand soap was locked and inaccessible to residents in care. LPA provided technical assistance regarding non-toxic soap being available for residents to use after using the restroom. Locked cabinets were present in each of the memory care bathrooms to store personal care items that required supervision for resident use. LPA began a file resident file review, but due to time constraints, Community Care Licensing will return at a later date to complete this annual inspection. According to the California Code of Regulations, Title 22, no deficiencies were cited during today's visit. A copy of this report was provided and an exit interview conducted.the state’s words, verbatim · CDSS document, Jan 28, 2025

Type of visit: Case Management - Deficiencies

On 12/6/24, at 3:20pm Licensing Program Analysts (LPAs) Kevin Gould and Holly Williams conducted an unannounced case management deficiencies inspection to deliver a civil penalty. LPA met with Director of Care, Misty Wilson, and together discussed the Department’s findings. On June 29, 2023, the department concluded the complaint investigation regarding the following allegations: Questionable Death The above allegation was substantiated, and the licensee was cited for the following violation of the California Code of Regulations (CCR) Title 22, 87705 (f)(2) Care of Persons with Dementia: The following shall be stored inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. The department has determined the deceased resident had an extensive history as having a preferred activity of smoking. Per family, resident being allowed to continue their preferred activity of smoking was a condition of living at the facility. For several years, the facility allowed the resident to smoke on their balcony unsupervised. Throughout the duration of the residents stay at the facility, the resident was allowed to retain and possess their own cigarettes and lighters and was permitted by the facility to smoke without supervision. The facility continued to provide supervision and care for the resident but not during their preferred activity of smoking. Resident records reviewed by the Department indicate the resident did have a diagnosis of dementia per Physician's Report dated April 26, 2021. Report Continued on LIC 9099-C. Per Title 22 Regulations, for residents with a diagnosis of dementia, items such as matches or cigarettes shall be stored inaccessible to residents in care. Per previous interviews conducted by the Department, the former resident’s cigarettes were not stored inaccessible to the resident which resulted in the reported incident on December 27, 2022, and the resident's subsequent death as a result of the injuries sustained. The Department concluded an analysis and determined that a civil penalty is warranted for the death of a resident as a result of a violation of Title 22 Regulations. Per Welfare and Institutions Code section 1569.49(e): for a violation that the department determines resulted in the death of a resident, the civil penalty shall be fifteen thousand dollars ($15,000). Today, December, 6, 2024, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49 for a violation that the Department has determined resulted in the death of a resident in the amount of $15,000. Exit interview conducted. A copy of the report issued. Appeal rights provided. Director of Care, Misty Wilson's signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Dec 6, 2024

Type of visit: Case Management - Deficiencies

On 12/6/24, at 3:20pm Licensing Program Analysts (LPAs) Kevin Gould and Holly Williams conducted an unannounced case management deficiencies inspection to deliver a civil penalty. LPA met with Director of Care, Misty Wilson, and together discussed the Department’s findings. On October 10, 2022, at 8:58 p.m., a resident (R1) pressed the call button to receive help to the restroom. Facility staff failed to respond to R1's call for help in a timely manner, causing R1 to get up on their own. R1 got up, fell, hitting their head on an unknown object. R1 laid on the ground for approximately 35 minutes before staff checked on them. Once staff found R1, they immediately called 911 and AlphaOne was dispatched at 10:49 p.m. R1 was transported to the hospital and diagnosed with a hip fracture. Staff openly admitted to failing to check on R1 in a timely manner, resulting in R1 falling, which caused R1 to break their right hip. The allegation of Neglect/Lack of Supervision for failure to seek timely medical attention is substantiated as staff failed to provide aid, which resulted in R1 laying on the ground for a prolonged amount of time. Per R1's care plan, R1 needs assistance with dressing, bathing, and toileting. R1 is a one-person assist. R1 needs escort service to the toilet. R1 called for help. Per records provided to the department, the facility staff did not respond to the call pendant pressed at 8:48 p.m. until 10:22 p.m. which resulted in the resident falling and sustaining an injury. Report Continued on LIC 9099-C At the time the complaint was concluded, an immediate civil penalty was issued for the amount of five hundred dollars ($500) per California Health and Safety Code section 1569.49(c)(1), due to the violations above resulting in resident injury. The Department concluded an analysis and determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code section 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death or protracted loss or impairment of function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including, but not limited to, hospitalization, surgery, or physical rehabilitation.” Today, December 6, 2024, the Department will be issuing a civil penalty per Health and Safety Code section 1569.49(f) for a violation that the Department constitutes as serious bodily injury in the amount of ten thousand dollars ($10,000). However, since an immediate civil penalty of five hundred dollars ($500) was previously issued on March 22, 2023, the amount of the civil penalty issued today will be nine thousand five hundred dollars ($9,500). Exit interview conducted. A copy of the report issued. Appeal rights provided. Director of Care, Misty Wilson's signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Dec 6, 2024

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit. LPA Moleski met with Care Services Director Misty Wilson and explained the purpose of the visit. This visit is to confirm immediate exclusion orders for a staff member (S1). Wilson said that S1 is no longer employed at this facility, effective 8/12/24, due to excessive call offs. Wilson acknowledged that this is an immediate exclusion for S1 effective 09/13/2024, which means that S1 cannot be allowed to work, live in, and/or have contact with clients in any residential facility licensed by the California Department of Social Services. Therefore, the Department orders the facility to remove S1 from any contact with clients and not allow this employee to be physically present in the facility. Wilson agreed to have S1 removed from the facility's Guardian roster as soon as possible. No deficiencies were cited during this visit. An exit interview was held with Wilson. A copy of this report and the immediate exclusion notice were left with Wilson. A signature on this report acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Sep 13, 2024

Allegation investigated: Facility staff not dispensing residents' medications as prescribed Facility staff not responding to residents' call lights for over 30 minutes Facility staff not meeting residents' incontinence care needs Facility staff not providing commode to accommodate resident's needs

On 09/06/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to delivery complaint findings. LPA met with Facility Designated Administrator (FDA), Ryan Nakao and explained the purpose of the visit. Current census was 78. A brief interview with FDA Nakao was conducted. Allegation: Facility staff not dispensing residents’ medications as prescribed It was alleged that facility staff are not dispensing residents’ medications as prescribed. During the course of this investigation, this LPA reviewed facility documentation, conducted interviews, and observations. Based on interviewed conducted with 7 staff and 7 residents, 7 out 7 staff deny that residents medication was not provided as prescribed. 7 out 7 staff state that staff dispensing medication are provided medication as prescribed and always ensure that medication is provided based on what the prescription order states. 7 out 7 residents state that they do not have issues with the medication being provided to them as prescribed. LPA reviewed the facilities medication administration record from February 2024-April 2024. Unsubstantiated It was observed that there were no discrepancies between the Medication Administrator Records and Physicians orders for all residents reviewed. In addition, this LPA conducted observation during medication pass. This LPA did not find any significant issues during medication pass. Based on the information gathered it is unclear if the facility staff was not dispensing residents’ medication as prescribed. Allegation: Facility staff not responding to residents’ call lights for over 30 minutes It was alleged that the facility staff are not responding to residents’ call lights for over 30 minutes. During the course of this investigation, this LPA reviewed facility documentation, conducted interviews, and observations. Based on interviews conducted with 7 staff and 7 residents, 7 out 7 staff deny that they are not responding to residents’ call lights for over 30 minutes. 7 out 7 staff state that some days might be harder to respond but there is not a time where resident’s are waiting for longer than 15 minutes. 7 out 7 staff also state that many times they forget to press the pendants to clear that they have responded. 7 out 7 residents deny waiting longer than 30 minutes when their call buttons are pressed. 7 out 7 residents state that staff arrive to their rooms within a reasonable time frame. A review of the facilities call button log shows that the facility averages response times from 5-28 minutes within the months of February 2024-April 2024. In addition, this LPA pressed call buttons of 4 residents and it was observed that response time was between 5 to 12 minutes within the 4 residents. Based on the information gathered it is unclear that the facility staff are not responding to residents’ call lights for over 30 minutes. Allegation: Facility staff not meeting residents' incontinence care needs It was alleged that the facility staff not meeting residents’ incontinence care needs. During the course of this investigation, this LPA conducted interviews and observations. Based on interviews conducted with 7 staff members and 7 residents, 7 out 7 staff members deny that they do not meet the residents’ incontinence care needs. 7 out 7 staff members state that they are able to meet their needs and change residents as needed and within a time frame if the resident is not soiled. 7 out 7 residents report that they do not have any issues and have not heard any issues about their incontinence needs not being met. LPA conducted a tour of the facility and facility resident rooms and did not observe any indication that the facility staff are not meeting the resident’s in continence needs. Based on the information gathered it is unclear if the facility staff are not meeting the residents incontinence needs. Allegation: Facility staff not providing commode to accommodate resident's needs It was alleged that the facility staff not able to accommodate resident’s needs. During the course of this investigation, this LPA conducted interviews and observations. Based on interviews conducted with 7 staff members and 7 residents, 7 out 7 staff members deny that they do not meet the residents’ care needs. 7 out 7 residents report that they do not have any issues and have not heard any issues about not being able to be accommodated with their needs at the facility. Based on the information gathered it is unclear if the facility staff are not able to accommodate resident’s needs. Based on information provided through interviews and records reviewed, this allegation is deemed UNSUBSTANTIATED, meaning that there was not a preponderance of evidence to prove or disprove that the allegation occurred as reported. There were no deficiencies observed or cited at this time. An exit interview was conducted, a copy of the 9099 and 9099-C was provided to the facility.the state’s words, verbatim · CDSS document, Sep 6, 2024 · control 27-AS-20240508104204

Allegation investigated: Staff did not keep facility free of insects.

Licensing Program Analyst (LPA) Kesha Lewis arrived at the facility unannounced to deliver complaint findings for the above allegation. LPA was greeted by staff and explained the reason for the visit. LPA Lewis conducted a facility tour and observation. LPA conducted facility tour with administrator. Observed were facility common areas, various resident rooms, kitchen area and hallways. Facility was observed by LPA to be clean and sanitary. Floors and walls were clean without prominent stains. Facility was observed to contain no foul odors. Food supply was adequate with 7 days of non-perishables and 2 days of perishable items in place. Fire extinguisher was full charged and dated 9-25-23. Room temperature was 71*F. Smoke alarms and carbon detectors are functioning properly. Current census is 93. No obstructions to fire exits noted during today's tour. LPA did not observe any insects in the facility during this visit. Cont on 9099C page.... Unsubstantiated Based on LPA'S observations and records received by the facility from a pest company that administers monthly services to the facility the above allegation is UNSUBSTANTIATED, which means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. No deficiencies were cited regarding the above allegation. Exit interview conducted. Copy of report given.the state’s words, verbatim · CDSS document, May 31, 2024 · control 27-AS-20240425143144

Type of visit: Case Management - Other

On 05/31/24, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to conduct a case management visit. The LPA identified herself upon arrival, stated the purpose of the visit and asked to speak with the Designated Facility Administrator (DFA). LPA met with Amanda Friedman and interviewed her briefly. DFA contacted Community Care Licensing to alert the office that she would be leaving Golden Pond and that 5/31/24 would be her last day. This case management is regarding the transition that will occur in her absence. DFA shared that her departure was planned and the Licensee had been advertising for a replacement. During the interim, the Care Director, Misty Wilson, who also had her Administrator's Certificate, would act as the Designated Facility Administrator until a new one could be hired. The DFA stated that based on her conversation with the Licensee, the facility would not have a gap in coverage. The LPA obtained an updated LIC 308, LIC 500, and resident roster. According to California Code of Regulations, Title 22, no deficiencies were observed or cited during today's visit. Exit interview.the state’s words, verbatim · CDSS document, May 31, 2024

Type of visit: Required - 1 Year

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.the state’s words, verbatim · CDSS document, Jan 22, 2024

Allegation investigated: Questionable Death

Licensing Program Analysts (LPA) Kevin Gould made an announced inspection to the Golden Pond Retirement Community on 12/6/23 at 9:00am to conclude the investigation of the above allegation and to deliver the findings. LPA Gould met with Administrator and together discussed the investigation details. Based on the interviews conducted during the investigation process and statements obtained during the investigation process, LPA Gould was unable to corroborate the allegation. The department has evaluated the circumstances of R1's death and the department was unable to conclusively determine the resident had passed away as a result of facility actions. Although the department can confirm that an incorrect POLST was provided to Emergency Medical Staff (EMS) responding to resident's distress, the EMS could not definitively state the resident could have been resuscitated by EMS efforts and the cause of death was determined to be cardiac arrest. The department could not definitivly state that the resident's death could have been prevented or was a direct result of facility actions. Unsubstantiated Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of Questionable Death are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. There are no deficiencies 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. The Department has investigated the complaint alleging Medications. Based on the investigative interviews, record reviews and other supportive evidence, the complaint is determined to be unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. The Complaint has been dismissed. There are no deficiencies noted or cited per California Code Regulation, TITLE 22. Exit interview was conducted with the facility administrator and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Dec 6, 2023 · control 27-AS-20230926111541

Type of visit: Case Management - Deficiencies

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.the state’s words, verbatim · CDSS document, Dec 6, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(1) · Plan of correction due date: Dec 29, 2023

Incidental Medical and Dental Care: The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by LPAs records review or resident's MAR and observed on 7/25/23 several AM medications were not documented as being administered to the resident and the department has determined the facility has not followed all aspects of medical care wich poses a potential health, safety and personal rights risk to resident in care.the state’s words, verbatim · CDSS document, Dec 6, 2023

Plan of correction: Facility will provide a written plan of correction to indicate the steps and process of medication administration audits to ensure that the facility has information on any medication or documentation error.