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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701508
Report Date: 08/26/2026
Date Signed: 08/26/2026 04:48:26 PM

Document Has Been Signed on 08/26/2026 04:48 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: 4DATE:
08/26/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:10 PM
MET WITH:Bulou Matamadua TIME VISIT/
INSPECTION COMPLETED:
05:15 PM
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
On 08/26/26, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to conduct a case management visit regarding a recent incident report that was sent in for an elopement. LPA identified herself upon arrival, stated the purpose of the visit and asked to meet with the Designated Facility Administrator, Bulou Matamadua (also known as Dede Nawasa). The Administrator was not present so care staff contacted her by phone and the Administrator arrived approximately 20 minutes later. A brief interview followed.

According to the incident report sent on 8/22/26, on 08/08/26, Resident (R1) had been up all night and after encouragement from staff, went to bed at 3:00 PM. Staff looked in on R1 at 6:00 AM but did not want to disturb R1 as they still appeared to be sleeping. When staff went in to administer medication at 7:00 AM, they learned that R1 had stacked pillows and clothes under their blankets so they would appear to be sleeping. The report goes on to state that the Administrator arrived 10 minutes later and drove around in search of R1. After searching for 1 hour, the Administrator contacted the local police. R1 told a good samaritan where they lived and that person came to the care home to let the Administrator know where R1 was. Both the Administrator and the police arrived at a local business to pick up R1 who was ready to go home at that point.

When LPA interviewed R1 in their room, they stated that they had snuck out. R1 could not remember which door they exited; whether it was the exit from their room to the yard, or through the front door. LPA checked the door in R1's room, and although it was alarmed, the alarm was not activated. When this LPA entered the room, she also observed a lighter on the floor. Per R1's LIC 602, dated 12/31/25, they were not to have access to "matches and similar items" and they were also "unable to leave the facility unassisted" These deficiencies have been cited on the LIC 809D page.
Lisa Rios
Kimberly Viarella
DATE: 08/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
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)
Page: 2 of 5
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: 08/26/2026
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
In addition to those two deficiencies, the another citation was delivered for not meeting reporting requirements as incident reports for occurrences on 08/08/26, 08/09/26 were sent to Community Care Licensing on 08/22/26 and another report for an incident that occurred on 08/17/26, was sent in on 08/26/26. LPA reviewed reporting requirements with the Administrator.

During this visit, this LPA provided assistance with regard to completing an application for a license for an Residential Care Facility for the Elderly.

According to the California Code of Regulations, Title 22, civil penalties were assessed today for the elopement. A copy of this report was provided, along with APPEAL RIGHTS and an exit interview was conducted with the Administrator.
NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Kimberly Viarella
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2026
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 08/26/2026 04:48 PM - It Cannot Be Edited


Created By: Kimberly Viarella On 08/26/2026 at 03:46 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: 08/26/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/27/2026
Section Cited
CCR
84711(a)

1
2
3
4
5
6
7
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:
1
2
3
4
5
6
7
Administrator set the door alarms while LPA was present at the facility. The Administrator stated she will conduct an in-service where she will instruct staff on conducting more frequent checks on residents. Staff will sign off on training and this will be emailed to CCL.
8
9
10
11
12
13
14
Based on record review and interviews with R1 and the Administrator, R1 was able to elope from the facility without staff knowledge. This posed an immediate threat to the health, safety and personal rights of residents in care.
8
9
10
11
12
13
14
Type A
08/27/2026
Section Cited
CCR87309(b)

1
2
3
4
5
6
7
Storage Space and Access
(b) Residents may have access...for personal use unless there is documentation ...that indicates the resident's or other residents’ safety would be at risk... The Licensee did not meet the above requirement as evidenced by:
1
2
3
4
5
6
7
Administrator locked the lighter in the medication cabinet for safe keeping and will instruct staff (during the same in-service) to assist with lighting R1's cigarettes and then to promptly relock it in the medication cabinet when done. Staff will also ask for any lighters when R1 returns from outings.
8
9
10
11
12
13
14
LPA observed a lighter on the floor of R1's room. This posed an immediate threat to the health, safety, and personal rights of residents in care.
8
9
10
11
12
13
14
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:
Kimberly Viarella
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/26/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2026


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 08/26/2026 04:48 PM - It Cannot Be Edited


Created By: Kimberly Viarella On 08/26/2026 at 03:58 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: 08/26/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/04/2026
Section Cited
CCR
87211(a)

1
2
3
4
5
6
7
Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:

The Licensee did not meet the above requirement as evidenced by:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Based on record review and an interview with the Administrator, 3 incident reports were sent to CCL past the 7 day requirement. This posed a potential threat to the health, safety, and personal rights of residents in care.
8
9
10
11
12
13
14

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.
Lisa Rios
NAME OF LICENSING PROGRAM MANAGER:
Kimberly Viarella
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/26/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2026


LIC809 (FAS) - (06/04)
Page: 5 of 5