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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701618
Report Date: 04/08/2026
Date Signed: 04/08/2026 01:46:03 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
04/03/2026 and conducted by Evaluator Arielle Pascua
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20260403101811
FACILITY NAME:SACRAMENTO SENIOR LIVING IIIFACILITY NUMBER:
342701618
ADMINISTRATOR:FELIPE NAIKASOFACILITY TYPE:
740
ADDRESS:8901 SONOMA VALLEY WAYTELEPHONE:
(530) 710-5707
CITY:SACRAMENTOSTATE: CAZIP CODE:
95829
CAPACITY:6CENSUS: 5DATE:
04/08/2026
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Peni Vuidreketi TIME COMPLETED:
02:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility administrator is not fulfilling administrator duties
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 04/08/2026, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a complaint visit. LPA Pascua was greeted by Staff Member (SM), Peni Vuidreketi and explained the purpose of the visit. LPA Pascua asked SM to contact the Facility Administrator to inform them that CCL was present. LPA Pascua was directed to call, Salote Charlotte Louis however LPA Pascua was unable to reach this individual. LPA Pascua also attempted to contact Facility Administrator but was unable to reach them via telephone.
The purpose of this visit was to inform the facility and its representative that a complaint has been filed aginst it at this time.
Current Census was 5. A brief interview with SM was conducted.
Upon arrival at this facility, LPA Pascua interviewed 3 residents and 2 staff members. It was stated that they do not know who Felipe Naikaso at this time. Further interviews reveal that they are not aware of who the administrator is at this home and have not seen the administrator. In addition, it was stated that Licensee Lewis does not answer their phone.
Substantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2026
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 5
Control Number 27-AS-20260403101811
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: SACRAMENTO SENIOR LIVING III
FACILITY NUMBER: 342701618
VISIT DATE: 04/08/2026
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
During this visit, LPA Pascua attempted to contact Licensee, Salote Charlotte Lewis 4 times via telephone at 12:49pm, 1:00pm, 1:07pm, and 1:15pm. LPA Pascua was unable to leave a voicemail due to the Licensee's voicemail unable to take messages. LPA Pascua also attempted to contact the Facility Administrator, Felipe Naikaso 3 times via telephone at 12:54pm, 1:07pm, and 1:14pm, LPA Pascua was also unable to leave a voicemail at this number.

Based on the information gathered through this visit, the administrator is not fulfilling administrator duties.
A civil penalty of $1000 is being issued today for a repeat violation of Section 87405(a) by not ensuring there is an administrator applicable to conduct administrator duties at the facility.

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.
The following deficiencies were cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes.

An Exit Interview was conducted and a copy of this report was provided to this facility at the end of this visit.
There were no signatures obtained for this facility report due to a representative not being available for this visit today.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20260403101811
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: SACRAMENTO SENIOR LIVING III
FACILITY NUMBER: 342701618
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/08/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/09/2026
Section Cited
CCR
87405(a)
1
2
3
4
5
6
7
87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation.
1
2
3
4
5
6
7
The licensee to submit 40 hour Administrator plan by 04/09/2026 by 5:00PM.
8
9
10
11
12
13
14
This is not met as evidenced by: Based on interview and record review, the licensee does not ensure that the administrator is present to meet with licensing staff, or adhere to administrator duties as required by the facilities plan of operation. This poses an immediate, health, safety, and personal rights risks to persons in care.
8
9
10
11
12
13
14
Type A
04/09/2026
Section Cited
CCR
87205(a)
1
2
3
4
5
6
7
(a) The licensee, whether an individual or other entity, shall exercise general supervision over the affairs of the licensed facility and establish policies concerning its operation in conformance with these regulations and the welfare of the individuals it serves.
1
2
3
4
5
6
7
The licesee to submit to have a plan in place to ensure that staff are present and available. This plan shall be sent to the LPA by 04/09/2026 by 5:00PM
8
9
10
11
12
13
14
This is not met as evidenced by: The licensee does not ensure that they are available did not ensure that an administrator or quailifed staff were available to meet with Licensing staff. This poses an immediate health, safety, and personal rights risks to persons 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.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5