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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701508
Report Date: 06/04/2026
Date Signed: 06/04/2026 04:14:22 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
06/02/2026 and conducted by Evaluator Kimberly Viarella
COMPLAINT CONTROL NUMBER: 27-AS-20260602154338
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: 3DATE:
06/04/2026
UNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Apakuki "Kuki" NawasaTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Due to lack of supervision, resident eloped.
INVESTIGATION FINDINGS:
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On 06/04/26, 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. Person that greeted LPA stated that they were not staff and were just helping out. LPA had person call the Administrator Bulou Matamadua. Matamadua explained that they were at work and would not be off until 3:00 PM. LPA asked who their Designee was as the person at the facility was not staff and should not have been left alone with residents in care. Admistrator said they were staff and had a file at the facility. The Administrator also stated that they would be sending their House Manager to the facility. LPA asked if the House Manager was the Designee, Administrator said no, not yet. LPA stated they would send an LIC 308 and that it should be completed and returned by the close of business today.

House Manager/Designee, Apakuki "Kuki" Nawasa arrived and an interivew followed. LPA learned that the person present at the facility was background cleared and had been in training. Nawasa explained

Substantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2026
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 4
Control Number 27-AS-20260602154338
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: 06/04/2026
NARRATIVE
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that staff (S1) may not have been aware that they were staff and had completed their training. LPA reviewed S1's file and noted a lack of documentation regarding training. LPA provided technical assistance regarding what training should cover and how it should be documented. This deficiency will be cited on a case management following this visit. Nawasa stated that he did complete the RCFE Administrator's course and has his certificate and would be restructuring his training and then retraining all staff.

With regard to the allegation, "Due to lack of supervision, resident eloped." During an interview with Nawasa, this LPA learned that R1 eloped though the gate in the yard. If there had been adequate supervision, this would not have happened. The Department found the above allegation to be SUBSTANTIATED. This deficiency has been cited on the LIC 9099D page.

According to the California Code of Regulations, Title 22, any other deficiencies will be cited in a case management following this visit. A copy of this report was provided along with APPEAL RIGHTS and an exit interview was conducted with the House Manager, Nawasa.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20260602154338
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: 06/04/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/05/2026
Section Cited
CCR
87411(a)
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Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary...

The Licensee did not ensure that the above regulation was met as evidenced by:
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Nawasa stated that they would develop a new training program that woudl follow the regulations and retrain all staff. An outline of the training and a schedule will be submitted to licensing by the close of business tomorrow 06/05/26.
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Per the House Manager, R1 eloped form the back yard. This posed an immediate threat to the health, safety and personal rights of residents in care.
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These materials will be sent to CCLASCPSacramentoSouthRO@dss.ca.gov
or Fax to (916) 263-4744
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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.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 4
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
06/02/2026 and conducted by Evaluator Kimberly Viarella
COMPLAINT CONTROL NUMBER: 27-AS-20260602154338

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: 3DATE:
06/04/2026
UNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Apakuki "Kuki" Nawasa TIME COMPLETED:
03:00 PM
ALLEGATION(S):
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2
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Staff mistreat resident.
INVESTIGATION FINDINGS:
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On 06/04/26, 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. LPA met with House Manager/Designee, Apakuki "Kuki" Nawasa. With regard to the allegation that, "Staff mistreat resident." LPA observed staff interactions with R1 during the course of this visit. Based on observations of R1's body language, speech, and actions, R1 did not appear to be fearful of the House Manager or S1. When this LPA spoke to R1, they explained the desire to go to Santa Cruz or San Hose, but did not express any fear of concerns for safety. LPA observed R1 sitting in the backyard with S1, and later watching TV in the common room supervised by staff. Based on a review of records, R1 was not a credible historian. Based on the above information, the Department found the above allegation to be UNSUBSTANTIATED. A finding of unsubstantiated does not mean that the allegation is untrue or did not happen, it means that there was not a preponderance of evidence to substantiate the allegation. According to Title 22 Regulations, no other deficiencies were cited during today's visit, a copy of this report was provided and an exit interview was conducted with Nawasa.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4