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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701508
Report Date: 05/04/2026
Date Signed: 05/04/2026 01:45:32 PM

Document Has Been Signed on 05/04/2026 01:45 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: 4DATE:
05/04/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Bulou Dranica MataduaTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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On 05/04/2026, Licensing Program Analyst (LPA) Arielle Pascua and Cosumnes High Utlizier Specialist (CHUS), Eddie Rachsein arrived to this facility unannounced to conduct a complaint visit. LPA Pascua met with Staff Member, Estia Nawani and explained the purpose of the visit. The purpose of this visit was in response to the complaint visits conducted on this day and the observations made. Shortly after, LPA Pascua met with House Manager, Apakuki Nawasa and Facility Designated Administrator (FDA), Bulou Dranica Matadua.

Current census was 4. It was learned that 1 resident was out at the hospital at this time.
During the course of this visit, LPA Pascua conducted a tour of the facility and reviewed facility records. While touring the kitchen, it was observed that the facility did not maintain an adequate two-day supply of perishable food. LPA Pascua observed an empty jar of pickles, an empty jar of salsa, a half-gallon of milk, a locked box, one mandarin fruit cup, mayonnaise, a bowl containing an unknown substance, and a package of turkey meat. When asked how often the facility obtains food, staff stated that additional food was kept locked in the garage due to residents eating during the night. LPA Pascua continued the tour into the bedrooms and observed that, in one bedroom, a bed was blocking the double exit doors. After moving the bed, LPA Pascua noted a lock installed at the top of the door that would prevent the door from being easily opened.
During the tour of the garage, LPA Pascua observed a sign indicating that residents were not permitted to enter the area. Upon entry, an air mattress was observed along with personal items, including chargers, a pillow, and a blanket. A second refrigerator was also present, however, it contained only a limited supply of food, including a box of pancakes, waffles, two gallons of milk, one chicken, cheese, and butter. The tour continued to the backyard, where it was observed that the back gate had been modified with a MagnaLatch child safety lock. LPA Pascua was unable to open the gate easily.
NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Arielle Pascua
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/04/2026
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: 05/04/2026
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In addition, a tour of the facility bathrooms was conducted, during which it was observed that both resident toilets were clogged at the time of LPA Pascua’s visit.

Based on today's visit, the facility is being cited for deficiencies noted in LIC809-D.
Additionally, the facility is hereby assessed a civil penalty of $500 each for Sections 87203 and 87202(a) for Fire Safety and Fire Clearance.

Technical Support Program was discussed during this visit.
An exit interview was conducted and a copy of this report along with appeals rights were provided to the facility at the end of this visit.
NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Arielle Pascua
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2026
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 05/04/2026 01:45 PM - It Cannot Be Edited


Created By: Arielle Pascua On 05/04/2026 at 01:00 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: 05/04/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/05/2026
Section Cited
CCR
87203

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All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.
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The facility shall remove the locks from the back gate and bedroom door. The licensee shall also submit a written statement of correction and ensure that staff complete at least one hour of fire safety training conducted by an outside vendor.
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This it not met as evidenced by: Based on observation the facility did not ensure that exit gate and bedroom door were not locked. This poses an immediate health, safety, and personal rights risks to persons in care.
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Documentation of the completed training shall be provided to LPA Pascua by the plan of correction (POC) due date.
Type B
05/05/2026
Section Cited
CCR87202(a)

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a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.
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The facility shall remove the air mattress from the garage. The licensee shall submit a fire clearance request to the Department to update the facility’s fire clearance, reflecting changes to the garage and staff occupancy.
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This is not met as evidenced by: Based on observation, the Licensee did not ensure that the facility garage was cleared for staff use. LPA Pascua observed an air mattress along with personal items in the garage. This poses a potential health, safety, and personal rights risks to persons in care.
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The licensee shall also provide a written statement of correction and ensure that staff complete a minimum of one hour of fire safety training conducted by an outside vendor. Documentation of the completed training shall be submitted to LPA Pascua by the POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lisa Rios
NAME OF LICENSING PROGRAM MANAGER:
Arielle Pascua
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/04/2026 01:45 PM - It Cannot Be Edited


Created By: Arielle Pascua On 05/04/2026 at 01:04 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: 05/04/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/05/2026
Section Cited
CCR
87555(b)(26)

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(26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.
This is not met as evidenced by: The licensee did not ensure there was a sufficient
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The licensee shall submit to LPA Pascua a plan to ensure the facility maintains an adequate two-day supply of perishable food. Copies of receipts and photographs verifying compliance shall be provided to the LPA by the (POC) due date.
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2 day perishable food supply at the facility at the time of this LPAs visit. This poses an immediate, health,safety, and personal rights risks to persons in care.
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Photographs and receipts shall be sent to the LPA weekly until 06/04/2026.
Type B
05/29/2026
Section Cited
CCR87303(a)

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(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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The licensee unclogged the toilet at the time of this visit.
The licensee shall submit to LPA Pascua a written acknowledgment of this regulation, along with a plan to ensure that the facility maintains fully functioning toilets.
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This is not met as evidenced by: Based on observation, the liensee did not ensure that the toilets used for resident used were unclogged. 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.
Lisa Rios
NAME OF LICENSING PROGRAM MANAGER:
Arielle Pascua
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2026


LIC809 (FAS) - (06/04)
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