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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701508
Report Date: 05/04/2026
Date Signed: 05/04/2026 01:48:21 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/02/2026 and conducted by Evaluator Arielle Pascua
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20260302155019
FACILITY NAME:SENIOR GUEST HOMEFACILITY NUMBER:
342701508
ADMINISTRATOR:BULOU DRANICA MATAMADUAFACILITY TYPE:
740
ADDRESS:8890 HARLOW CTTELEPHONE:
(702) 629-0201
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 4DATE:
05/04/2026
UNANNOUNCEDTIME BEGAN:
10:23 AM
MET WITH:Bulou Dranica MataduaTIME COMPLETED:
02:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not provide adequate supervision to residents in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
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 to deliver complaint findings for the allegation above. 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. Based on the information gathered, R1 eloped from the facility on six separate occasions in January 2026, as well as on 02/15/2025 and 04/08/2025. Interviews further revealed that on one of these occasions, R1 was found at a major intersection on the same day. During today’s visit, LPA Pascua observed R1 leaving the facility and had to alert staff after the resident exited the premises. A review of the resident’s physician report indicates that R1 is not able to leave the facility unassisted.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR 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.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 27-AS-20260302155019
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
 Based on the information gathered, staff did not provide adequate supervision to the residents in care.
As a result of this investigation, this LPA found the allegations to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met.
Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are cited on the 9099D during this visit. An immediate Civil Penalties of $500 are being issued today for Section 87411(a).

Licensee was provided a copy of their rights (LIC9058) and their/or representative's signature acknowledges receipt of these rights.

An exit interview was conducted with Apakuki Nawasa and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR 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
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20260302155019
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
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
87411(a)
1
2
3
4
5
6
7
(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This is not met as evidenced by:
1
2
3
4
5
6
7
An immediate civil penalty of $500 was issued for violation of this Section.
Licensee will provide a statement of correction, along with proof of training from an outside vendor for no less that one hour in duration regarding AWOL procedures.
8
9
10
11
12
13
14
Based on interviews and record review. The Licensee did not ensure adequate supervision of residents in care. R1 has eloped from the facility approximately 8 times within this year and is not able to leave unassisted. This poses an immediate health and safety risk to the R1 in care.
8
9
10
11
12
13
14
Licensee shall also update AWOL procedures. A copy of training and these procedures shall be provided to to the LPA by POC date.
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR 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
LIC9099 (FAS) - (06/04)
Page: 3 of 3