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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701508
Report Date: 01/09/2026
Date Signed: 01/09/2026 03:48:35 PM

Document Has Been Signed on 01/09/2026 03:48 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:SENIOR GUEST HOMEFACILITY NUMBER:
342701508
ADMINISTRATOR/
DIRECTOR:		BULOU DRANICA MATAMADUAFACILITY TYPE:
740
ADDRESS:8890 HARLOW CTTELEPHONE:
(702) 629-0201
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 5DATE:
01/09/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Bulou Matamadua, AdminTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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On 1/9/2026, Licensing Program Analyst, Arvin Villanueva (LPA), arrived unannounced at this facility to conduct a case management visit. LPA initially met with staff on duty, Carlos Samayoa (S1), and stated the purpose of the visit. One of the facility manager, Apakuki Nawasa (S2), was notified. S2 is unable to come to the facility immediately and designated S1 to assist with the visit. Present during this visit were 5 residents in care with one staff on duty (S1). The Administrator Bulou Matamadua (AD), arrived at 11:45am.

During this visit, a resident (R4) had an unwitnessed fall. Prior to the fall, S1 was in the kitchen preparing their lunch meal. LPA heard a loud thud sound and observed R4 lying on the bathroom floor. LPA observed 2 small pieces of countertop tiles on the floor next to R4's head. R4 seizured for about 10 - 15 seconds. S1 called 911 and they arrived about 5 minutes later. LPA overheard S1 reporting to the Emergency Personnel that R4 ran out of seizure medication 2 - 3 days ago. R4 was assessed by Emergency Personnel with no visible injuries. Review of R4's medications confirms R4's medication bottles were empty. Review of R4's medication administration record confirms R4 was out of seizure medications on 1/7/2026. Other medications ran out beginning 1/5/2026. R4 was taken to the hospital for evaluation and for seizure medication. Interview with AD revealed that R4 currently do not have an established primary physician but did not plan accordingly to ensure R4 received their medication refills.

Purpose of this visit is to obtain additional files for Complaint# 27-AS-20251112124819.
  • LPA obtained copy of resident files belong to R1 and R2 for further review.
  • LPA obtain copy of facility files, including staff schedule for November 2025, resident roster from November to present, and facility policy on resident drug use and resident rules. R2's documents were not at this facility during this visit. The facility manager had to go to another facility to obtain R2's documents.
NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Arvin Villanueva
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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

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

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

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

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

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

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

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

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

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

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: SENIOR GUEST HOME
FACILITY NUMBER: 342701508
VISIT DATE: 01/09/2026
NARRATIVE
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Purpose of this visit is to recite deficiencies from Complaint# 27-AS-20251208152635.
  • LPA is reciting the facility for not submitting the Plan of Corrections (POC) set on 12/17/2025. Facility was cited for CCR 87464(f)(1) Basic Services and it was due 12/18/25. Facility was also cited for CCR 87468.1(a)(2) Personal Rights of Residents in All Facilities and it was due 12/24/25. The Department did not receive these POCs.

Purpose of this visit is to cite deficiencies observed during complaint visit on 12/17/2025 (Complaint# 27-AS-20251208152635).
  • During a visit on 12/17/25, LPA observed a door knob lock on a chair by the front door. LPA asked staff (S3) regarding the door knob lock and stated that they (staff) use a door knob lock to secure the front door knob to prevent residents from opening the front door and going outside. It is a door knob cover with combination to unlock. S3 demonstrated to LPA how they use this device. During today's visit, LPA observed the door knob lock on a dining table located in the living room area. This is a repeat violation. The facility was cited for this violation on 9/11/25 and will be assess a civil penalty of $1000 for repeat violation during this visit.
  • During a complaint visit on 12/17/2025, LPA discovered, through record review and interviews, R4 had an elopement incident occurred on 12/15/25 and emergency hospitalization due to psychiatric problem on 12/1/25. Through LPA's verification, the Department did not receive these incident reports.


Based on today's visit, the facility is being cited for deficiencies noted in 9099-D. Additionally, the facility is hereby assessed a civil penalty of $1000 for repeat violation. Facility is hereby assessed additional immediate civil penalty of $500 not ensuring resident received their seizure medication timely, which resulted in seizure and fall.

Plan of Corrections and due dates were discussed during the exit interview.
Copy of this report and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Arvin Villanueva
LICENSING PROGRAM ANALYST SIGNATURE:

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

DATE: 01/09/2026
LIC809 (FAS) - (06/04)
Page: 10 of 13
Document Has Been Signed on 01/09/2026 03:48 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 01/09/2026 at 10:54 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: SENIOR GUEST HOME
FACILITY NUMBER: 342701508

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/10/2026
Section Cited
CCR
87468.1(a)(6)

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Residents in all residential care facilities for the elderly shall have all of the following personal rights: To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This does not prohibit a licensee from establishing house rules, such as locking doors at night to protect residents, or barring windows against intruders, with permission from the Department.

This requirement is not met as evidenced by:
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Corrected on site: Administrator discarded the door knob lock in the trash can.
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Based on observation and interview, the licensee did not comply with the section cited above. Staff are still placing a door knob cover equipped with combination lock on the knob of the front door to prevent residents from leaving without supervision.This poses an immediate health, safety or personal rights risk to persons in care.
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Facility administrator agrees to retrain staff. Proof of retraining shall be submitted to the Department by 1/16/26.
Type A
01/10/2026
Section Cited
CCR87211(a)(1)

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Reporting Requirements: 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 any of the events specified in (A) through (D)…\This requirement is not met as evidenced by:
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Administrator agrees to submit a written statement of understanding of the regulation related to reporting requirement. Statement shall be submitted tomorrow 1/10/26.
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Based on record review and interviews, the licensee did not comply with the regulation cited above. LPA discovered that a resident (R3) had a hospitalization on 12/1/25 due to psychiatric issue and same resident eloped on 12/15/25. The Department did not receive incident reports for these incidents. This poses an immediate health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Arvin Villanueva
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2026


LIC809 (FAS) - (06/04)
Page: 11 of 13
Document Has Been Signed on 01/09/2026 03:48 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 01/09/2026 at 11:10 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: SENIOR GUEST HOME
FACILITY NUMBER: 342701508

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/10/2026
Section Cited
CCR
87464(f)(1)

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Basic Services: (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).
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Per discussion, the licensee or its designee will submit a statement of understanding regarding the cited regulation. Written statement must be submitted by tomorrow, 1/10/2026
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Based on interviews, by admission of the facility manager, there were 2 instances where resident was not adequately supervised: one was when was reported by neighbor urinating on the street; and another instance where resident eloped, and staff did not follow. Record reviews showed is not able to leave the facility unassisted. This poses immediate health, safety and personal rights risks to persons in care.
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Type B
01/16/2026
Section Cited
CCR87468.1(a)(2)

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Personal Rights of Residents in All Facilities: (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 is not met as evidenced by:
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Per discussion, the administrator will conduct a staff training related to Personal Rights and proper communication with residents. Proof of training must be submitted to the Department by 1/16/2026.
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Based on interviews, by admission of facility manager, staff yelled at residents and deemed it inappropriate. This poses a potential health, safety and personal rights risks to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Arvin Villanueva
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/09/2026 03:48 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 01/09/2026 at 12:22 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: SENIOR GUEST HOME
FACILITY NUMBER: 342701508

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/10/2026
Section Cited
CCR
87465(a)(4)

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A plan for incidental medical and dental care shall be developed by each facility…The licensee shall assist residents with self-administered medications as needed.
This requirement is not met as evidenced by:
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Administrator agreed to submit a written plan to ensure all residents in care receive their medication on time and ensure residents' medications do not run out. Plan shall be submitted by 1/10/2026.
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Based on observations, record reviews and interviews, the licensee did not comply with the regulation cited above. Facility staff did not ensure that R4 received their medication refills on time, including their seizure medication, which resulted in R4 sustaining a seizure and fall during today’s visit. This poses an immediate health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Arvin Villanueva
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2026


LIC809 (FAS) - (06/04)
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